NAME OF THE COLLEGS

DECLARATION FORM ! 2OT8.T9 - RESIDENT (36/JR}

{kcT

(Nore : It is r.epoBibiliiy or Dera HoD & teidenrddrdion foli of r.sident, {ho h re not ipP.nsd

1(b) DaE of Bidh & Ag€ .....rzi..1.u..t..1.1.1.*../ ....

1.(c) subnit rhoto ID proor issued by Govt Au$oriti6 :

Photo lD subnttred: ,/P:5+o*€ry/ nl| +tu / vot€r ,o/tuc|*€r.d.N,^t*,. .2,!.1-.1384?a . .. .. r,sued by

r.(d)ii.

1.(d)iv.

1.(d)'.

campus / ?r€seni addres!

try oin* As6smenr 4/1in which

I - UC/Ilc Assmenr 'n

rhe $me

Mcl - ucll'c a$c$mmt d 5ame

8./ze.4i;.. 6- ^Ai':

ao..Note: 1) withour Phdo !q Declaration forn will be cject€d and {ill nd be considsed as

tea.hing fa.!lty, 2) OriSinar Cc ificates are mmd ory foi veificarior AllC€*ifi cates/Docune.tycof if ied Tiandailqns, nEr

wherher appeged and ac.epred in tn* |

Whether appoied and acepted in Last

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r*a

I

1.(0 copy df Rmn Alloine r? e$pmfni'h'd Y6/No

1.(s) contaciparticurm: tettoftn),-]L?E: 243s.@ @i$sm..a.)

Dahorrommspl*d chtubon I

loininS repon at the pr*nt iEhtuh atlached

1.(h)

1.(! v{n.

Peiranent Addr6s or R6ident

o.,- l3a t no

v.p0"1+rhqb'al.c

2oo7 3?@2

z4/e

MD/MS/DNA 4.rlr,o*&

2p(-2o9 '|clo -

r.i;te For r,C-Post IIC ,i! alilication additional Regista tion .er tifi.a te Particulas be funnhed and

subjft b€ lurnishcd wiihin bi:.keb a{rer soring out ! l'ichever k nor aPPli.able.

2(a) Cop i€s of D.gre cedi fi (ates oI M BB S and PC degree atla.hed - Yetr{o

2.(b ) Copies of Registration of MBBS and PG degee rnached YetNo

lo/k4L2! loq2o/L

/h'rl,#"'6oc ltralat zt/b64 /3

f,Jnq,tt 6"9 ,t&hel zrbalz"u A/oI/2o/,r.{:,M,q/ at/o1/t{

4. Debils ol Lhe baching experien@ till drre

a.(a) BeroF joining presenr iGnbrion I was wo'kins at

rgisnins /TrNrerins /(Reli*i$ order is endose.l fron the Previous imtitution)

5. I h.ve drawr tobl shpend from ihis coUege in 6\e cuiienr finan.id year as under'

ttllD:A.i,gtas

'V

an ultdeirt,nS rhar | :m i Full tine

No1llL in t.

tdoing any Privale pra.tice or not working in any oow hGpital

I have nol sorked at int other medi..l college/insbtubon or pRnt€d nyplt at anyArssndt in the cudent acadehi. yenrIt is d<lared L\at each shtemeit and/or onrenb of Lhs d(lrarion and /or drun€nb,cerdficac submited alonS with the dedrniion forh, by rhe undecisned are absoluhlytruq coret and authenbc. In rhe evenr ol my sbrement hade in lhis d<lararidsubseqlently turning our ro IE in.ored or falP $e undeBigned h6 lndeBrood anda.€pbd ihai such fGdclantion in res*ct b any .onknt ot Lhis drldation shal also behea€d d a gro$ r'{Fdld $p-br Fndera8 dE troe'5.Bned hab.e ro' nf.Ftar)-'':;;;

;- ""-'v'''Itu

tum'ft'n

""..^l-... ,-.ffin' "

P6'dcnb Honcl 'n

$erclleg€ prc

'Ihis endor*ment j3 the crhficaiion $ar ihe undeEiBned h6 satislied himrer /heRttab.nt lne o@h6s and veh.ity of emh conenr oI this d<lalarion and endor6 tneabovenotioned dRlaration as trueand ordl I hrvc veri6ed rhe.€nificaiet dodnenhsubnfited by the .andidale with rhe originrl .eiilicatev dGrnenr as rubnifr€d by rheR€sident to lhe institute dd wifi the .on.erned institute and hive found rfien ro be

2. I also coniirm that Dr. is workLng r frll rme Regul:rnBidpnr n e fo' 24 hor6) rnir r,' or pid b i' s or .a,,v.n8 or any oJr.r ftiliry rd i5n.) i,,s - R..

" N. 42y' orn"n.,.a,r -.p i'.,o "sepemr6. nn.eh-/,h.

ha joined ihe Imiibte.

3. h lne 4mi ot rhis declaiation iurning our b b€ eilner imou<r or any pad ot ihisdelarahon subsequendy tuming our ro b€ incoriet or fake jt is mdesr@d and a@pkdlhar $e underigned shau atso be equally Hpo'sible b€sides the dRtannt hireu/heGerfor any su.h n,isne!l:rurion of m6bremenL

P.he, [Jt1.!@ryDr. A.K. ABDUL KHADERRe9. No:e057 WAS, MD,OTCO

Dept.orPuttretolyKMCT Mediel Colr6d.

*.le'

7. R*nt Papon si4 photo ol the Enploye, Si8ned bt Dean / hincipalor the collgge.Phoro ID, proof isucd by Govr Auihoities : Paspoi C;py / pAN Ca.d

Cenified @pic. ofp'en r,ppoinr ner I order o, pF,.r. inrirure.copy ol Allohnent Lener by Dg.n as pr@l of presenr rcsidene aaot6.copy of Pa$poit /voiergard / Ekricity Biu / Tetephd€ BiI /{$Ird, Cdd JnJ.l"d d5d pr@. or p-' T rF i 'qio!n(eadd'-!.IoiniiA report at th-" pEenr,ishrutr.Copis or DeFR.dbf,.i6 o, MBBSand PGdesrecod6 of Reshrabon ot MBBS and ?c desr@.Copy o p\p+'ience.i

'dh,r' ro-,lldpNinrmrc h"td h1oc io.nirg

Reriains oder fron L\e pievious inshturion.

W.\'sided bv rhe Residentl

D!&i D!l!rlj

sAei

arr. A.K. ABDUL KHADERNgg No.e057 rES, O,oTcD

Depr ot pul|ll@togyrNlCl Med @t C.lt€le

Manassery, Kozh,kod., X.Era11'

a9siaed & verified bv rie Asse$oi :

P4!j

NAt!!Tlp DcdJd:on rorm wi rorbe r-!-phd drd rhe per.on s! nor be.ounred aiR6id.nr ifrn, orrhe Jbo\edo(LhenB re nor enCojed/ rdt'hed wirhlhe D^tration tornThe?ssn wjn rct be suded as a Residenr il rhe originit of phoro ID pioot R€sisiraiioncedtri.ales/ Degree .ertifi.{es / FAN Card / MCr Snart ID Crd/€rate Medicat Coun ilID ( if issued ) re noi produced for verjtication ar rhe rine of a$6!nen..All the Resident n*t slbmft the revipd decrarition forh in this formi onlq (anvdtrrdrion rorh eubmikd,n:n old fo'n, k:lt nor bp Jc, cpred i.d h" *itJ not b;..";h;

INAME OF THE COLLEGE:

DECLARATION FORM : 2O18.19 _ RESIDENT (SR/JEf(Nok:rri5,sPoEibirity orDeJn

,,.. -"." ft ?i&+l Nlrb, Drpolstr$d

^"," alla.l.ra6 .3l'6a

1.(c) Subnit Phoro lD p.of issucat bt covr urlroriries :

,.rEs!^+ "-pr,/ P,u\Le€rrvrr'o€-rE/AidhY? crrd.r"-*,.6€{6. {511 85Pd.. . .. h*..r

Noe 1) wnhour Fhoto ID, Dectrrrrion roinr Bitl be rejected ind wil .ot be.onsideEd ast€a.hing facujty. 2) (tiginal ccnific cs rrc nuMrtory for veriE.rtion Arlcenifiater/Document9/cenifiedTr slarion5,nusrbein[ngrhh

.'llr^1,!n. QoxfJ,,1h

,"c,a.) o'r,. ^*-,."nddH' *r.'.h

wheiher appean'd and aecptn i,r rist Mc iclrrc A$6shent 'n

rhe s.me

whether appeatu.r itrd a(rprsd n, r-u* rircr dcTrc Assment on sins

camp$/ Prescnt dPs or lteji.{edt:

, - ^, 'i;;;;i corrr4t

1.(d)i.

lld)n.

1.(0

1,(g) ConhtPdjculaE: Tel(Offie):

1.ft)

1.0)

2-

loininsEpo ar ri. pconr iNtii,h.&-h",1- .l6//|N"

Pdn.n€nr Addrs oI R6id€nr:

copy ot Rms Arrdb.nr |.deudp.tulnenr 6l& ht.ddrd pEof,hr.n.d. {46lNc

Dah orjoinins pr@nr i,x,i,ution , lr,lalaotA * 1' "t*.ifufiluX

Note }or PGPGT PG qu.liaErion add ioMl Rqistsation eltifiole partidlm b. fsnlrhed edsubjct b€ tur$bd widin bEckeb afbr sorins out whichwer is rot applicable

2(a ) copi* of DegR edifi€ts ol r,l6Bs and lrc d€gl* alr*h€d -\a€qnto

z(b ) Copk, ot Residnrion or NrfBs rnd Pc desre d*hed l<No

MBES dall €s{l+slulrr TLIIL

MD/MSlDNB

DM/M,Cn,

ttrltns@',Yk'{# @ rsr&lL6 9,

4.{a) B€tore jojning pruent iEritutioi I w6 worrnis ar

Eigdi'g /Thistd 's

/Gelievjng order is €n.loed rion rhc pPviour iElit{don).

5. I have dhwn tobl sripod tom this ollege i. rle .fi€nr limnciat y6r as undei.

D€biL of dE h.hine e, penen€ rill dare.

3C 3?q34q48

r1

.Nlt kA11-{ Mednar

'heq I€LLp(,i c,

2. Furtncr, I stah that I am not Joing i,y lrlivire padie .r not rvorki'rg in any oih{ hospibl

L I have not worked ar aiy oihc' modi.alAssmenti'r rhcctr'"enrao.lcDn ycii

college/iroiit(iion or prGented myse[ at my

Itis dedared that.ich sbrefrent r /.r lrntenb ol llris {tedr}ation and /or d@henls,.ertili.aG submii(d alors with tho J..lirition Jorm, by tlt unde'sisned aF absolurelyhue coret trnd iuthenrir I" tL( rreot oa a.y nrhDenr made nr ihis d(lannonslhseqlently rumi,g our b be inn,lcr or fake ine undcrsign€d h$ unde*bod anda.epied drat n'ch n,is.lslarirlo,r ir r+r(t toanl conrontor this dedirahon shallaho beteaied a i grcs mis.onduct ihorcb (mtcing th. unrl.rsigned liable ror Esaryd, . .pj 1,ry '.

' on / n, l ' rg' n ..lJih. ,.m^f.oml.l.r V.d.dlRegDE')

.t t+ l+

2.

3,

resident (i.e. i.r 2r horE) anJ'iayins n Rod, No 41 6

"*" 4S6- m re

1 This endor*nut is thc .cfrifi.ahon th th. undcsigned hrs satisticd hins.lf /he6elfalnut the on{h.s .fd vcrr.ity of crdr cont'nt oI tl s ldffation md fldo66 rheabovenentioNd dedararion I tu rnd co' ffi Ihavaverificdihe.€iili.ateydo.um.ntssubnittedbythecnndidrtcwiththco,igimlceftifi.atetdo.umenEasslbnittedbythe

n ,forkn,B is ltru time Rqularor ca'rling out iny oth.r a.hvity and nIloi.l i, .,,11.!,S pre'n,16, sjn@ he/she

tu 'Jng

out ro be.irhrr irorfti or &y pa of thisort tu tre i".orret or fil! ii is und.rnood and aeepredo.ldJlly !EpoNible berides rl'e declarint himselr/he6€lt

.,,nL* I//x4'I !r i!, isncn !$ \6mp 0y th.

DrAX AEDUL KHADERD e si D4"/Pr rtipdlx.i M:e57 Msas, M0, orco ... .:r,ic..

"I#SffJR" ,r're rc'':!e -

".*"9. Y11'-."J "-""t

3l-11 -i

n4 N]r&Mr6.g

!!Ettl!!(5

srE i

4{'4

Jfl'tlffi;.- ?rildrd -^,,...

Sifted &veriried bv tlre Asscssor.i

p3ls-r

7.\QI!i

The D<lrrarion F,oin will not b.r..epted rnll the pe6on \{ilt nor be counied as R*ident ifanyottherbovedo.ur€nk ire not endoscd/ adred sirh the l)eclarition Forn.The perso.will nor b.cornrld rs i Resi'lerr ilihcoiginrlof lhoio lD proot Regiir{ioncetiri.rtes/ Dearee (!rtiri.rps / PAN ctrrd / Mcl srrd lD crrd/state Medi.al colncilID (irhsu.d ) rre notprodu.cd roi v.rilicrrior I tlrc time otrssetsmenr.All the Residenr nu* subn rhc rovisrll Jcdration torn in this fornat only. (Anydedaration forn subnlred in rn nd he$illnot be.ollted

R{entPasport s a rhlb.t ura Ell\] o}€,signed N D.rn / Prin.iprr

Ihoto lD pnt rssugr lrt G.vt Aurho itns: Pa$poltcopy / PAN car.lvoe D LoM rl

C"r ]',ed cones. ore er' rr"i' n.,.' dcrat prc.1 r, L-Copy of Alkn'nedtr?tr by Dcan as Fiooaotpiese.t resiltenceaddr*s.Copy.l Pastoir /vor., Ca d / !I.(r!.iy Biil / l.lcphone B I /Aadhar cald'atta.hcJ r\ r !rt{f of Ler rDenr rcsidcnlr rdJie$.

5. toirins rcpiri Lh. fr \fri'+nutrcopies ot Dcqr.{ rertinnG! .I \Copics ot Re*i\6rh.. ol lvlBBtand Pai Jqreccopy ol.rt. icrrc.cnticitr, for rrl .Lp|ti mgnb hc{lLxtoRjoinn'g