NAME OF THE COLLEGE:

I 11 III IV

Date of Assessment

Accepted? (YESjNO/ABSENT)

Name of the Assessor

Signature of Assessor

1.(a)

DECLARATION FORM: 2014 - 2015 - FACULTYName G S.y(f.1..m..A..l..A ..~ .Date 01 Bi,th & Age IS> 0 1·1"110 4., 49?Recent Passport size photo of the EmployeeSigned by Dean / Principal of the college.

Submit Photo ID proof issu<;l-by Govt. Authorities , I~tcat\l11Photo ID submitted: .:»: ~.¥. oos.Passport copy / PAN Card/ Voter ID / Aadhar Card - ~ fA. •.620

Numbe,8KW:f'~I(£Q~J+ Issued by ~!:\~1~H~t:.:J--

1.(b)

1.(c)

l.(d)

(Without Photo ID, Declaration form will be rejected and will not be considered as teaching~~ R1.(e) i. Present De'ignation'~~ < S.~ ~ +~_~ _1.(e)(i)a Certified copies of present appointment order at present institute attached.

Department e Vb., <h~_- _College ~{dcL:u14 li~ GtJ G,~City \J~II-1f'Id~ .Nature of appointment: Regular / C~tual.

Residential Address of employee:

1.(e)ii.

1.(e) iii.

1.(e)iv.

1.(e) v.

1.(f)

1.(g) Have you undergone Training in "Basic Course Workshop" at MCI Regional Centrein MET or in your college under Regional Centre observership? .~

Yes [;JIf yes, give details.

Name of MCI Regional Centre where Date and place of trainingTraining was done/ If training was done incollege, give the details of the observerfrom RC

1.(h) Copy of Passport IV oter Card / Electricity Bill /Telephone Bill / Aadhar Card attached as aproof of residence.

1.(i) Contact Particulars: Tel (Office'{:R;b c., -..2. 4- co ~q0 .Er+- 2.11·

Tel (Residence): (with STD code)

(with STD code)

E-mail address: _

Mobile Number 9 ~6 s ] 9 ~ ~ .Date of joining present institution, '2, I - 0 3,. 9.D1 t- as =~=.k-- ~6L--

1. O)a Joining report at the present institute attached.

2. Qualifications:

Registration Name of the StateQualification College University Year No. ofUG & Medical CouncilPG with date

n., .,..".~ C\ ~b 197 3 '1 ~b .~J,>J-esJ i~l-MBBS~. cg'Ob .'10 (pUAA-~ !&'l~·

MO/~ ~A~~ NTRu .2.Obb~ ~~bM~( )

~9 fr 1+.S . ~t)1. ~ '0),,'(( .

(' 4\J.. 1N!'1.u \

OM/M.Ch.( )

Note: For PG-Post PG qualification additional Registration certificate particulars be furnished andsubject be indicated within brackets after scoring out whichever is not applicable.

~ Copy of Degree certificates of MBBS and PG degree attached.

J.-{t5") Copy of Registration of MBBS and PG degree attached.

2

3 (a). Details of the previous appointments/ teaching experience

Designation Department Name of From To TotalInstitution DD/MM/VY DD/MM/VY Experience

in years &months

Tutor/f~~~~

~C-~ Ilr;;-~~ to~~uh 1.~.Demon tr to~ V~'~ • f') /1,,1_ f') ,"1,') qRegistrar/ U "-J U USenior Resident/Resident

Assistant Av~~W;

S fY\ c. ~'D~' 11~~

~~Professor

V(\~"w~r

Kf'()~ .(\'V

AssociateProfessor

Professor

Note:- Registrar/Senior Residents working in Anesthesia and Radio-diagnosis must have 3 yearsteaching experience in the respective departments in a recognized/permitted medicalinstitute as a Resident.

3(b). To be filled in by Ex Army Personnel only:

S.No. Place of Posting Designation PeriodFrom To

1.

2.

3.

4.

5.

3

4 .(a) 'on I was working at Ifl.'.sct'hh ;'N~(~ as-.l..-\a-=i;;"J-l.A---"=-~--""'t--tt-t-'------- and relieved on 9.n. 03., (I . ::Cter

order is enclosed from the previous institution).

4 .(b) I am not working in any other medical college/ dental college in the State or outside the Statein any capacity Regular / Contractual.YE~·

5. Number of Research publications in Journals during the last 3 (fhree) academic years:-.

5. (a) International Journals: _

5. (b) National [ournals: _

5. (c) State/Other Journals: ---'-~ _

6. (a) My PAN Card No. is A k lA) P0 ~ ('0 2.. H-6. (b) I have drawn total emoluments from this college in the current financial year as under:-

Amount Received TDS

July

August \. _ f\ /

September (2'0Y ~October ~

/ \/November ~

~\J,J--J ~\

December 'v\ ~'J \<"'"(l \ <r: '\January r Xr-J'-/ \~ ) ~, ~February

-:7 / ..»"

March \ y ~\JJ'>r: r-; 0April \. r ~ / ,r-..!'--,-,!May V

June

6. (c) (Copy of my PAN & Form 16 (fDS certificate) for financial year __ are attached)

4

-

1.

DECLARATION

I, Dr. 4' ~ 1'6VD A:LA am working as A.s..+ ~~ in the

Department of ~p b"'~ at ~~~edical

College and do hereby give an I!ndertaking that I am a full time teacher in

~ D ~ A], , working from -+-A.M. to -4- P.M. daily

at this Institute. U2. I have not presented myself to any other Institution as a faculty in the current academic year

for the purpose of MCI assessment.

3. am practicing at

__________________ in the city of ,.--- and my

am not having private practice anywhere OR

hours of practice are .,-- to _

4. Complete details with regard to work experience has been provided & nothing has beenconcealed by me.

5. It is declared that each statement and/ or contents of this declaration and / or documents,certificates submitted along with the declaration form, by the undersigned are absolutelytrue, correct and authentic. In the event of any statement made in this declarationsubsequently turning out to be incorrect or false the undersigned has understood andaccepted that such misdeclaration in respect to any content of this declaration shall also betreated as a gross misconduct thereby rendering the under. igned liable for necessarydisciplinary action (including removal of his name from Indian edical Register).

Date: 61· 11· ('1 .

Place V Ui OJAJ ~

ENDORSEMENT

1. This endorsement is the certification that the undersigned has satisfied himself /herselfabout the correctness and veracity of each content of this declaration and endorses the abovementioned declaration as true and correct. I have verified the certificates / documentssubmitted by the candidate with the original certificates/documents as submitted by theteacher to the Institute and with the concerned Institute and have found them to becorrect and authentic.

2. I also confirm that Dr.G . S Y A IYj A.LA. is not practicing or carrying out

any other activity during college working hours i.e. fromqA-1Y'\ to ~ since he/she

has joined the Institute.

3. In the event of this declaration turning out to be either incorrect or any part of thisdeclaration subsequently turning out to be incorrect or false it is understood and acceptedthat the undersigned shall also be equally responsible besides the declarant himself/herselffor any such misdeclaration or misstatement.

Date: ol· t\. I~ .Plac"V~t~c{\N~

. ~'--'~ I \\\1 cf)v-~~b-~ ~"_....-..-- xfr /Signed by the HOD is {P (~ Countersigned by the

Director / Dean/ Principal

PRP~CIPJa.SlDDH~RTH~MEDICALColLEGE

GOVT. OF A. P.vljAY:.\'/v'AD6.-520 OOR

REMARKS

S.No Documents Submitted1. Recent Passport size photo of the Employee, Signed by Dean / ~es / No

Principal of the college.2. Photo ID proof issued by Govt. Authorities: Passport / PAN \./"'Yes / No

Card / Voter ID / Aadhar Card3. Certified copies of present appointment order at present ~/ No

Institute.4. Copy of Passport /Voter Card / Electricity Bill / Telephone Bill ~es / No

/ Aadhar Card attached as a proof of residence.5. Joining report at the present institute. ~es / No6. Copies of Degree certificates of MBBSand PG degree. Ae§./ No7. Copies of Registration of MBBSand PG degree. ..;fes / No8. Copy of experience certificate for all teaching appointments .....-'fe"s/ No

held before joining present institute.9. Relieving order from the previous institution. 0es / No10. PAN Card ../'fes / No11. Form 16 (fDS certificate) for the last financial year. ~es / No .A

12. Letter head (in case of teachers who are practicing) Yes / No./

Signed by the HOD: /J-- ~ ~Date: & ( t I ( ,~ .

Countersigned by ~rincipal:Date:

NOTE:

1. The Declaration Form will not be accepted and the person will not be counted as teacher ifany of the above documents are not enclosed/ attached with the Declaration Form.

2. The person will not be counted as a teacher if the original of Photo ID proof, RegistrationCertificates / Degree certificates / PAN Card / State Medical Council ID (if issued) are notproduced for verification at the time of assessment.

3. All the teachers must submit the revised declaration form in this format only. (Anydeclaration form submitted in an old format will not be accepted and he will not be countedas a teacher.)

6