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Staff Declaration Form




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


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


Date of Birth & Age--------------------
Qualification College & University Year Registration No. 
with State Pharmacy Council
Name of the
State Pharmacy Council


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


Name of Institution



Total Experience in years









Reader / Assistant Professor




























  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


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)



Circle : ______________________



  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 :


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 :