NAME OF THE COLLEGE :

_____________________________________________________
I II III IV
Date of Assessment
Accepted?
(YES/NO/ABSENT)
Name of the Assessor
S!nat"re of Assessor
DECLARATION FORM : 2014 2015 RESIDENT
(SR/JR)
1.(a) Name....
1.(b) Date of Birth & Age ..
1.(c) Medical Reg. Council Number ...
1.(d) Recent Pa!ort i"e !hoto of the #m!lo$ee
%igned b$ Dean & Princi!al of the college.
1.(e) %ubmit Photo 'D !roof iued b$ (o)t. Authoritie *
#hoto ID s"$mtted :
#assport cop% / #AN &ard / Voter ID/Aadhar &ard'

Number . 'ued b$ ....

((tho"t #hoto ID) Dec*araton form +** $e re,ected and +** not $e
consdered as teachn! fac"*t%)
1.(f) i. Preent
Deignation*+++++++++++++++++++++++++++++++++++++++++++++++++++++++++
1.(f)(i)a Certi,ed co!ie of !reent a!!ointment order at !reent intitute
attached.
1.(f)ii. De!artment*
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
1.(f) iii. College*
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
1.(f)i).
Cit$*+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
1.(f) ). Nature of a!!ointment* Regular & Contractual
1.(g)i. Reidential Addre of em!lo$ee *
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
PHOTOGRAPH TO
BE
COUTERSIGNED
BY THE
DEAN/PRINCIPAL
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
2
1.(g)ii. Permanent Addre of em!lo$ee *
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
1.(h ) &op% of #assport /Voter &ard / Te*ephone B** / E*ectrct% B** / Aadhar
&ard as proof of resdence'
1.(i) Contact Particular* -el (./ce)*++++++++++++++++++++++++++++++++++++(0ith %-D
code)
-el (Reidence)* ++++++++++++++++++++++++++++++++ (0ith %-D
code)
#1mail addre*
+++++++++++++++++++++++++++++++++++++++++++++++
Mobile Number*
++++++++++++++++++++++++++++++++++++++++++++++
1.(2 ) Date of 2oining !reent intitution * +++++++++++++++++++++++ a
++++++++++++++++++++++++
1.(3)a 4oining re!ort at the !reent intitute attached.
5. 6uali,cation *
-"a*.cat
on
&o**e!e /n0erst% Year
1e!strat
on No' of
/2 3 #2
+th date
Name of the
State 4edca*
&o"nc*
MBB%
MD&M%
(
)
DM&M.Ch.
(
)
Note: 7or P(1Pot P( 8uali,cation additional Regitration certi,cate !articular
be furnihed and ub2ect be furnihed 0ithin brac3et after coring out
0hiche)er i not a!!licable.
3
5.(a ) &opes of De!ree cert.cates of 4BBS and #2 de!ree attached'
5.(b ) &opes of 1e!straton of 4BBS and #2 de!ree attached'
4
9. Detail of the !re)iou a!!ointment&e:!erience
Des!naton Departme
nt
Name of
Instt"ton
5onn!
Date
1e*e0n!
Date
Tota*
E6peren
ce n
%ears 3
months
-utor 1& 4R 1
-utor 5& 4R 5
-utor 9& 4R 9
%enior
Reident 1
%enior
Reident 5
%enior
Reident 9
; .(a ) Before 2oining !reent intitution ' 0a 0or3ing at
++++++++++++++++++++++++++++++++ a ++++++++++++++++++++++++++++++++++++ and
relie)ed on +++++++++++++++++++++++++ after reigning (1e*e0n! order s
enc*osed from the pre0o"s nstt"ton).
; .(b ) ' am not 0or3ing in an$ other medical college&dental college in the %tate or
outide the %tate in an$ ca!acit$ regular & contractual.
< .(a ) M$ PAN Card No. i ++++++++++++++++++++++.
< .(b ) (Co!$ of m$ PAN & 7orm 1= (-D% certi,cate) for ,nancial $ear ++++++++++ are
attached)
DE&7A1ATION
1. '> Dr. +++++++++++++++++++++++++++++++++ am 0or3ing a ++++++++++++++++++++++++ in
the De!artment of +++++++++++++++++++++++++ at +++++++++++++++++++++++++++++
Medical College and do hereb$ gi)e an underta3ing that ' am a Regular Reident
in +++++++++++++++++++++++++++++++++++++++> and am ta$ing in Room No. ++++++++ in
the Reident? @otel in the college !remie.
5. ' ha)e not 0or3ed at an$ other medical college&intitution or !reented m$elf at
an$ Aement in the current academic $ear.
5
9. 't i declared that each tatement and&or content of thi declaration and &or
document> certi,cate ubmitted along 0ith the declaration form> b$ the
underigned are abolutel$ true> correct and authentic. 'n the e)ent of an$
tatement made in thi declaration ube8uentl$ turning out to be incorrect or
fale the underigned ha undertood and acce!ted that uch mideclaration in
re!ect to an$ content of thi declaration hall alo be treated a a gro
miconduct thereb$ rendering the underigned liable for necear$ dici!linar$
action (including remo)al of hi name from 'ndian Medical Regiter).


SI2NAT/1E O8 T9E 1ESIDENT
Date*
Place*
ENDO1SE4ENT
1. -hi endorement i the certi,cation that the underigned ha ati,ed himelf
&herelf about the correctne and )eracit$ of each content of thi declaration
and endore the abo)ementioned declaration a true and correct. I ha0e
0er.ed the cert.cates/ doc"ments s"$mtted $% the canddate +th
the or!na* cert.cates/ doc"ments as s"$mtted $% the 1esdent to the
nstt"te and +th the concerned nstt"te and ha0e fo"nd them to $e
correct and a"thentc'
5. ' alo con,rm that Dr. +++++++++++++++++++++++++++++++ i 0or3ing a Regular
Reident (i.e. for 5; hour) and i not !racticing or carr$ing out an$ other acti)it$
and i ta$ing in Room No. +++++++++ of the Reident? @otel in college !remie>
ince he&he ha 2oined the 'ntitute.
9. 'n the e)ent of thi declaration turning out to be either incorrect or an$ !art of
thi declaration ube8uentl$ turning out to be incorrect or fale it i undertood
and acce!ted that the underigned hall alo be e8uall$ re!onible beide the
declarant himelf&herelf for an$ uch mideclaration or mitatement.
Date*
Place* %igned b$ the @.D
Counterigned b$ the
Director&Dean&Princi!al
6
1E4A1:S
%.No Document %ubmitted
1. Recent Pa!ort i"e !hoto of the #m!lo$ee> %igned b$
Dean & Princi!al of the college.
Ae & No
5. Photo 'D !roof iued b$ (o)t. Authoritie * Pa!ort
Co!$ & PAN Card & Boter 'D & Aadhar Card
Ae & No
9.
Certified c!ie" f !re"e#t $!!i#t%e#t rder $t !re"e#t
i#"tit&te'
Ae & No
;. Co!$ of Pa!ort &Boter Card & -ele!hone Bill & #lectricit$
Bill & Aadhar Card> a !roof of reidence.
Ae & No
<. 4oining re!ort at the !reent intitute. Ae & No
=. Co!ie of Degree certi,cate of MBB% and P( degree. Ae & No
C. Co!ie of Regitration of MBB% and P( degree. Ae & No
D. Co!$ of e:!erience certi,cate for all a!!ointment held
before 2oining !reent intitute.
Ae & No
E. Relie)ing order from the !re)iou intitution. Ae & No
1F. PAN Card Ae & No
11. 7orm 1= (-D% certi,cate) for the lat ,nancial $ear. Ae & No
15. Getter head (in cae of Reident 0ho are !racticing) Ae & No
S!ned $% the Teacher : S!ned $% the 9OD:
Date : Date :
&o"nters!ned $% Dean / #rncpa*'
Date :
S!ned 3 Ver.ed $% the Assessor :
Date :
NOTE :
;' The Dec*araton 8orm +** not $e accepted and the person +** not $e
co"nted as 1esdent f an% of the a$o0e doc"ments are not enc*osed /
attached +th the Dec*araton 8orm'
<' The person +** not $e co"nted as a 1esdent f the or!na* of #hoto ID
proof) 1e!straton &ert.cates / De!ree cert.cates / #AN &ard / 4&I
Smart ID &ard /State 4edca* &o"nc* ID ( f ss"ed ) are not prod"ced for
0er.caton at the tme of assessment'
=' A** the 1esdent m"st s"$mt the re0sed dec*araton form n ths format
on*%' (An% dec*araton form s"$mtted n an o*d format +** not $e
accepted and he +** not $e co"nted as a 1esdent)
(