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Staff Declaration Form

PHARMACY COUNCIL OF INDIA

STAFF DECLARATION FORM


From,
 

Teacher's Name --------------------------
(as on University Degree certificate) 

 


Recent Passport size photo of the Employee Signed by Dean/Principal of the College

 
Photograph

Date of Birth & Age--------------------
 
Qualification College & University Year Registration No. 
with State Pharmacy Council
Name of the
State Pharmacy Council
B.Pharm         
M.Pharm     
(Ph.D.)/others    

 

Copies of Registration Certificate and University degree/PG/Ph.D. be attached.

 

Present Designation : _____________________________________________________

 

Department : ____________________________________________________________

 

College : _______________________________________________________________

 

City : __________________________________________________________________

 

Nature of appointment : Permanent/Temporary/Adhoc/Honorary/Part-time


Whether belongs to : O.G./SC/ST/OBC/Ex-service/Others


Permanent Residential Address of employee :  ____________________________________________________________________

 

Copy of Passport/Voter Card/Ration Card/PAN No./Electricity Bill/Driving License Attached as a proof of residence.

 

Phone & Fax Number  with Code

Office: ________________________________

Residence: ________________________________

 

E-mail address : _____________________________________


Date of joining present institution: ____________________ as  __________________(Designation)

 

Details of the previous appointments/teaching experience

Position

Name of Institution

From

To

Total Experience in years

Lecturer

 

 

 

 

 

 

 

Reader / Assistant Professor

 

 

 

 

 

 

 

 

Professor

 

 

 

 

 

 

 

 

Principal

 

 

 

 

 

 

 

 

  

  1. Before joining present institution I was working at ______________________ as _____________________________ and relieved on ___________
    after resigning/retiring (relieving order is enclosed from the previous institution). 
     
  2. I am not working in any other Pharmacy College/Medical College/Dental College/Industry/Community Pharmacy/Hospital Pharmacy/Govt. Service/any
    other service in the State or outside the State in any capacity full-time/part-time other than the above.
     
  3. I have drawn total emoluments from this college as under :- 

 

Amount Received

TDS

April, 2005

 

 

May, 2005

 

 

June, 2005

 

 

July, 2005

 

 

August, 2005

 

 

September, 2005

 

 

October, 2005

 

 

November, 2005

 

 

December, 2005

 

 

January, 2006

 

 

February, 2006

 

 

March, 2006

 

 


(Copy of my form 16 (TDS certificate) for financial year 2005-2006 is attached)

 

P.A.N.:_______________________

Circle : ______________________

 

Declaration:

  1. I have not worked at any other pharmacy college/institution or presented myself at any inspection for the academic year 2005-2006.
     
  2. It is declared that each statement and/or contents of this declaration made by the undersigned are absolutely true and correct. In the event of any
    statement made in this declaration subsequently turning out to be incorrect or false the undersigned has understood and accepted that
    such misdeclaration in respect to any content of this declaration shall also be treated as a gross misconduct thereby rendering the undersigned
    liable for necessary disciplinary action (including removal of his name from Register of Registered Pharmacists).


Signature of the Employee:  


Date :
Place:      

 


Endorsement :

This endorsement is the certification that the undersigned has satisfied himself/herself about the correctness and veracity of each content of this declaration and
endorses the abovementioned declaration as true and correct.  In the event of this declaration turning out to be either incorrect or any part of this declaration
|subsequently turning out to be incorrect or false it is understood and accepted that the undersigned shall also be equally responsible besides the declarant
himself/herself for any such misdeclaration or misstatement.


Countersigned by the Director/Dean/Principal in respect of Teaching Staff


Date : 
Place: