1(b) DdeorlJjdh&Asc..tr: )cz.=lA3 .L . 6.+,1r.1G) strbdritPhoLotDI oorislren L,rco{

^trLtn tu$:

P*sporcopy/ paN.d /v.r"- rry*rn\+{rrd

<t1zQf _rrnl Pa g oa+7 oFat.*--

4ofE ta4_ o. Sauj.lE4 )/F.p,' '{ 4 E^t1=ll 4 L (tt{a

1a a.,LT rnL-tt. /r.- aat t € C /_-

l.(d)v,i N|[rrr ir*i !(t :rlt irn rrc.r ir _in \rat uc/rr:; .\s.sndjr o, s.nn.'. ..r,,.\ ./+"

-_1. P';"1 Ittat - ,o4 ot t, D _L_-t2 -

-rs4DD.!ftnit- ,,",,",,,..

", "..(^ic.*' ..

r.ft)iii

r.(d)iv.

N*0cd lll)rreiirht (i)

(,)

Rlr,ti ,.tuu,L $]]f.u firl /r4rtr Ll@i\

NAME oF fHE cgLLEaE L fiL7- afi..'ltaAc aALLc C)_:

pEcLARAT|oN FoRM, 20i8-19 _ FAGULTL(Nde I rr h.LsPotrsir,ilityorDorD

6.-d;rkr.Er..r"r N.* Dz..P .2. tl t:rayA.leq rn.a4 ..

9, 4:D. vt AL

7e

r.(e) (!) p.nanenr !€sidcntial Addie$ of Ehployee :

o_2, H I

tI4Lk

8.azs t2/.P 2-

N A /72Art &-a.t - ltg

r.(4Y"^#i ;tfiil:1,"ilT,i"x;;iil,:1,fi ,y"Tfl;i;LT.' Resi.m, cM,re

Lk)

r.6)

copy or pssporr

^de!€r:d /."*n.a *. p,_, or *,ia"".J

1. (4

r.0

conractparhcurab: M (onie) :__e+g:;!Z+ar!eeth s.rn 6r")rorr'*ir.*9 q !'

D:re ofjohr,s pEentRlrubon O? o6.2oar> t

*nTy:_-@Fmm;-tt,s", et."

't" a"i;r ilit,)""iliii)

Di 'e

-r,r l,r@-;;;;;;

Joining ftp.4.rthepresentnstituteatached, y6/!t -P_!!qr,=-r,ro z

Note Forrc Po* PC qualifjcatior additional Rcgistation cenili.atesubjRt beafterscod'rgort{h.hcvern NtaPPlicabl.

2.(a) copyof Degrecertificdes of MBBSandIcdegi€eaitached

2. (t,) CopyotRegistrtion ofMDBS and PC de8r.e atia(hed -Yet}ld

/oLraI o? 2oolrtlett.a

parti.trl.rs Lx frtrtrnhd rid

R.gisviiion I Name olrhcshteNo. hithdrre I MeJi.rl Cotrn.il

.Aq.q T t19/ceffJPa,

DM/M.Ch.

I (a) Der,isor$c icirhrge.per e' !e tillJite

6Yr ?m-tt.+.tc.,o

l4.e.ta%tu I. iaq"l+.q L@+ 9t. I

?'*l:::3\{ ttu1

y'e.,..^71o.,, ,-xl!-y.ot to,* TNL_

611-

t_

Nore! Turor/ Residenr *orkins '. ^ne{hesiaexperien.e i'1 rhc resp.dive d€p:rtfrenb

.onsider rs $nior !.sid.nr.

and Irrdio-dirgn.sis nnarin i rc.osnized/pernritted

ro be 6len in by Ex Amy Pqsonml onb4

1.

Noia ltiv. yd h€€n comideEd in any UC/rlC isperion at .ny orhe. iMrituiion/meii6l .oIeRduringlat3tgE.If y6, pl.se give dera0s.

5.

c,zcisning / 6Fc /rrd.f€trs (R.lieving order

Numhd or Rerch public.tioG in lndex Jolrmls:

5, (a ) In[ern.rioml Iodrnits:

s.G) sbE/ttubtodon.rlournar!:

123 /La.a uy a^ar-,^,av..x 61'47 37?7 33+6

qAa/Y\r hasa

MayZJnlo quno. LCqro

I lure drawn tohl enolumenb ton thk col%e jn rhe cuir€nr tendar y€r s und€.-

6. (c ) (copy ot my PAN & Iom t6 OD6 certiri..k) aor rinan.iat yeal 201et7,r. ar[rched]

DECLARATION

3.

r nave not pGenred nyelf ro arv orherReidenr in lhe curmr a.ade'njc ya; for rhe

r am nor havnrS Private pr.ctice

ott;ev. fr).<C€tLa * 1( m(.7 Medkatdo he'chv q."

fu4!9Qd:"et,.^I an a tull lihe reacher i,r

41AM !o 9 PM. daily

M€dical cottege / rNrjtuhon .s a raculrv /purpGeofMCI a$ssnenr.

anywhere OR r "- F-ftritir€ :t

5.

houa ar,phcti@ are_ to _.Fur$e, I sbre rh.r r an nor doing any privar€Practi€ornorworkinS inanyorherlbspiral durinscotj%ehouB.cohpl.F ddarh w,L1 FSMj b wo,t apeirqte h.F txFn.prov.d4 6t no.h,n3 h4 &-nIar rct holing m Jv orhF. Tedicat o %e, d. i:t(olt%e,n the Shh o, oubide lnpSbkm,n) cdpa(itt.R%uhr/conbdcr,utr ran- ._r,,tri-i, n",rr_erlo,m.y.

It ir d*lared thal o.h rblem.nr.ndlo' cont nb of thjl deliEtion and /or d(unen6'li"--* "'u.li"a "r*"

. ',r'

Li" lehF on rora bv tlF uda si$ed iE 'h'oluElvi,i -'L, "'a rutt'e.tii r" rt'e *ot ot 'nv

shEnqt m'dP in tnk drhdds

"],-*'"ii,i.,ri .*" .* . t*

'rcBt ot r.L. ttF unddisned k yd':9'1 .l''d

"*';d lh;r such ;i6d<1..'ion in rBP..l b tnv<onbnr o[h( d

ta[J c a g* mir-^a*t tt'sPbr rendedng th'mdtrrign€d lirbl' Ior n{eryai*io[,,".v".i"^t'*t,al"e'"-ov.lof hi4.amefrcm lndi'n Medi6l R"BrqEi

STCNATIJRE OFTHE EMPTOYEE

oq\o?l\rPbe Nlot^o63e!

ENPOBSEUIIII

Thb enddEemetrt i3 the enification tst the undercign€d has srrBfied himsetf /heelr

"i"iJ. -*.* ,,'a *."ttv or .a.h conbenr o, this d<lar'hon and endD66 the abde

i*t-"a a.an.m. ot u,. -d sm.L t hrv? velfi'd the 'dtifictrer

/ ddument5

;;'nJbv tl'e c.ndid,hwi'h tho odgin,l (etrifi"rey'documenc a'lubmllted b' rhe

;i;. L" th! hsdtde ind with rhecon;,ned rnrrlur.'nd h:ve fdndthem to be orRr

t.b.snnf, t!1atDr. t1. t). v t).-:1ale ',

nor pn.hcins orca'ry'n3 our

.nv oths.(dviry durins, ollqe tYhVl-*6 ' e r,.. -€-e -l+Z@srke he/'h-

In rh. dot of ths delahtion hmi$ out to b€ enher incor€t or anv pait ol thir

al"ir.. "'u""q*"ry r"'t.e oul b -b€ incor€ L o' rdl5e tr i3 undsrod dd rGPtsd

rL"iii" ,J."*'i.a ,r'Ltt "u t equtlv ' 6PoD'ble b6d6 rhe ddrd him*l/tuFlr

td any such nisdelar.tion or nishlfle.i

1tuc.mhdisned Fltfi 3f"F y th€

Drector/Dean/Prin.iPalo"e6q16plr1Pt"* [,iOMA%a

K$ct ffif*tt*t

! lieRc.cntPi$podsi?pholo ofd,eEnPlq€q sl3n..l by Dci,r /

Phoro lD proolksued bycovt A,{horitjes Pasport / l'ANcard/votcrID/ AadharcardCenilied coiies or paenr appojnhnetrto(ie.il prcsenl

CopI of Pa$pon /vol?.Crd / El.ctniry Bill/ IelePhonea ll

/ li(ihr Cid / Deart rLLoh.nt lcttcr drxd,.dasa proot ot

Copy ol Pa$pod / Voier Canl / Elctri.ily !i[ / Tc]ephore Bill

/ Aadhar card atacl'ed as r prcot or pcl!!q9{4!!!gE9:JonnnE itpoi rt the Preseni ins!!ql!:Copid ol Dese ccnifict!\ .I lvl

Copi€io l{e*Frd.tolMLILS, nd'C hA rt.copy of crpc, ience cenili.ite Ior all tci.l,i'rg iPpoi'nD. nsh.ld trcfoF roi'rjn* p'esent i'Liitute.Pehc!ns drlef lro$ rl e p,cv'ons trrhtuho'

Flrf rb0Ds!or .i(tr' rLol:+l',rLr rlirr2trcL heid ('n!.e lkr.Lc,iho crrr.i'3)Capy of U c re.ognizcd tci.her lerefl.Dn a0iliarcd

Copy ofP.G. rao3 ?d iei.her left todrifriliatedUnilcrsity.(Ior P C Asssn.nt)

4t.,uSkned b\ rhcT$.htr ,]-]-

--{u.--Pl<l o\ldtlllprBr ortlo?ll1

CounreEiqned wifh {rmp by

9i

Pler 0610+l ,?. ,-,

IqIqThe Declarrlion ftrm will no; be ic.epred and rhe peson will mor be counrcd $ icrdre' itanyolihc'abovedo.rnpnrsarc noi encio$d/itti.hed wnhrhe D*hration rornThe peKon vill not be .ounred rs r ierdrcr if the origiml ot Plroro ID Prcol ltegistarioicediri.rtes/ DcsBc .crtiri.tes/ rAN card / sriie Medi.il corn.il lD (iI ksu.d) ft noiprodu.ed for verili.ation it the tiAII ihe tei.he6 mun suLrmit the relked dedrntion lorn in this fo.frri only. (Anyd{rr ion fo.D n'btuitted in i'r old tornii sill not be a.cePred rnd hc will norbe.ountod

/uc t Aea(AL (?2LLaJ tNAME OF THE COLLEGE:

1.(d){Di

pEcLARATIoN FoRM: 2o't8-19 - FAGULTY(Nd., xisnrposiL'irr'yof Don.

ertr'dworki"strfurr'h*)

r rir f . . ri .^1dllA,lDAs p. €l021.195' '' 'a

1(c) submitl'hotulDt'oorj$Lalbrcoi.r\rilrmtics:

p$?&or}/ PAN crd / \1{** {}/*ftrffiI?ir

\,,,,.6",.\P1 ?6 ( 3q: tJ.

Note 1) wiihou. Photo ID, Dcd& ion lon ,vill be lej€dad a

teachiry fi.ultt. 2) orieinal c€iific*cs ire dind*orv for verlri.itioi AIICeiiri.JegDo.um$ttcciif ied Trinslitions, rr{ be in English

r (d) PLso D\ !n ri.' PAc,Festda aF svqt ct'/

I rrlPk.nl

on-t- ,t GtNet|*L SuP6e"/

c.rhs" l<f.!It'-4AAASae.aY, t4at<eo*t

(')

Resur., /c.r]rl* /rkftrrullr I /rr I hm./lI0ro.{y

3f : 3S"Sx;;'t'%9'' -',9Cf1^;qilf r;^"r;ueg{6h!* *n'"'@t.*-?3-11:!!!Y.a!!:!\rhctlre] rp|lei({ ii(l a..epred i'r i.ist N{CI - UC/|C Asr.s'rent i,, rr nnne

h'herl,er )p0arred ias vcr UC/PCDcsigniton Ycs/*6

D.5!,\n a1 l?oFc<toe aF trecw.

N,

lffi t Re'denrial Add@s of dptoy€ :1.(e) G)

Ct-lErA

1.G) 6) Permn€nt R6idential AddR$ of EnDtovae :

3t/at64 e .goBtlA-na^/ RaAD

PO 6rat7

Hav€ yor udergone TEining in "Basic Colrse workshoC, ar Mcr Regionar Ce.rre

'nMEf oti lon cotlegc nder Regionl CanE obserue5hi??

,* l4

1.(h) conhcrp.rticular: ret(onice)._931! Z?3aPp

1.(4

1. (D

1.0

Nane of MCI Regional Cenhc whereIrdj\jngwas Am/ If trainnA urc do . ,tblege, gia. the .tetdib o! the ob*tut

Dite ard plce ol birnrng

I.{d clpy or rA,pql /vokr c:rd / th.khity BiI /bndrine Tcrephone Bi / Aadhr crd/rE:chedas. pref of rcsiden(0. Yes/lL,ro

let l96id6€: .24 ^,

4 s4ae4-

DareofFinirs prsr 'Gritutjon

ll - or- 2t\T

En.iraddr*: rlr^a^rlzsFr-^@ eo6l''hMobire Numbe, +4t Ot &v 5?t 0e4_

,oinins Eport al the prenr itutitub anached - y6/Nn{^, Wa$'6a al st

^ti@t-

t,,tsi

college Univ€dry

cazr;iHE$ L

t tesy';1

Noie r{r Ic l'od l'C qui Liri.trd, i!l(litn, r negrhtnrr.e iiririte rrt(r,$ tre rtrr,islr(li!'L,jcd bedcrsoinrur *r'i.hCopydf Degrce(e.rlrj.iles orNtBRsindPcLl.grecrth.hcd Ycs/No

copy oI lteginrriion of NrrrrJS rnd rC ileCi€r rti.hed - Yes/No

Der ls oI rhcicid,i',grrpoicrcc t Lldit.

Dn/MNr,A.Y Dn/\rNnl

b ti. ,tli ,^""'<

* a ",2"-

6Xu !'t'k

?

(d.T 4e:2.^t_. u ".2e1t

:a at z'r 6'y ra",*

2l**

,z "o

*e Lf c)"--*

Nor+ Tutor / RsidcnL worLn8 nr /\ncihcsir ind l{idio<lia8nosn N6i hrvc I rrs rcad, ingeiperien.e ii d1o .espedive dapirthent in r re.ognizeqpei,nifie.oosnierrssqdnrrcidctrr

Dr4Lr\)

c+41 .ra.!r )1 A ClL

3(b), To be 6lledin by E arny PeM.nel onlvl

Noe Hav€ yN ben oreidsrd 'n

.nv UC/ IrC ,nsP€iion ar in)

during l6t 3 yas. lf y6, Ple& give dehils

B.for ioininB pEenr 'Nntorion

. err {o'r'ns * @ !%Lgg" "esE!!4 8_44E!t- c1d reti?v?d o^ z'44:z9LiEigeing / 4lidng /T€{€I€rrig (R€lievins otde. is endosed rbm the Fcvious

5. Numb€rof ReerKhPubli(itions'nlndelouirDls:

5.(a) lnFmatimrllounal!:

5,(c) shh/lBtitorionalJoum.ls:

6. (., MTPAN card No ir

olher iEritution/ned'61 college

b. (b) MyAadhrr6rd No. i3

{.) I halednwn toritenrottrnrenb t.m rlns.oIqte j,r F (trrcnr aimi.iitvcifas tr(tef

F.r r | '5!.'l .'.1 I nr. r[ .r ri! i' r],r)

f iotcfu i, r, Lr t,,. I.

coll$e ii(l (lo lrerott Jivs h trndcnak trrj rLr I ,D a iull hnc r..rljer ir

- 6;-e,-oaL ru'Vzt- _ *.r,s i.,:i,r u b /- r.\r ,r",r,.

b rrL 'rh.r

r !1.trc rhir I ,rn noL Jdirg Ioru horprhr !r1,r'!.o r$ hou !

!..

Resi!drr.d,..L 'r.nL,u!tc

trr.l.,r n, Lh!

r itr' rr 'iyrr8 Pnvrt P'i.ri.!

"."--"1,,.-.",,.",aoDrpror. dd,'irs \irh rqt d

\j.(ri.i Grhr / i,\ihruor i..i hn'rL\ /p0roir ri Mcl i*t$De L

rr),$ uc on I inr tnr(i. r! iL

5. l:n'dot\okinSi'rary.rhe ncdi.at.. e[./do]rat..ltelreuttrcsrire.r.osntcrr.sr.rri i i rr.r$ftr: lic!uli /cod,,,du,rt,,,\dho.---t:L,l rinr./ f.n'rinr,/ Hdr,rtl

Irjsd*]8Fd,lh e4 5 \hFmd and/or oalgns of rh.s dstd"hon ind /or drumcnh,ed(ab ubmihed atdS wirt, rle ddjArfion to,r bv Lf u.ieF,8rcd a'.,,b{nrurFty

euequPnly tudng ou. kt." lhe , nde,srSnpn hr6 undeEred ddacpidl ihd such nisdehhrion in rup€.t !o any conrbr ot $ls drtahiion shal a|$ ;rrd a3 .i 3.c mh ondxr r\prbr Ffde,ns LF und"^isreo tiro.e ror nG.floF,pnrdvachon (in(rud 1g lmoval otn's n,.mef,od tndhn M"Jhr RegBF4

D"!", o\lorll+flae [101A069)

ENDORSEMENT

r, Tnis endo emenr is the @{itjcation rtEr rhe undersiSned has sarjdied himselt /ho6elt.bui the rcrcrn* .nd vera.ity oI each conient oI ihi; detaration and oldo* ihe abov€nenboned ddararion as bue and oq<r. r have v.rilied the .dtifi."6 / d&un;;Nbmthed by rheondidre wirh rhe orig:nrt .errilicrpydoomente r( \ubn rod by rhc

he.on,erned Inrirdeand h,ve found rh.m robelo,icd

3,

r ar$ rcnrirn ihar Dr pan n^dhaqdl@j is m, pnctrc[g or.afyirs out.ny orie' adivfy d!'nr8 mlese woft,rg hous i.e. rro,n -tfl4 b {}[{l,4 6iie lP/she

rn E 4en o. rhs rftti'dtior tum,G oLr b L,e " he nR-,,r o, .,ry pd4 nr I FanrnrcisbsaenrD run\i"3or rob. ro,.ftrtrh!,d s Lre^rom "id,rt.rF!l"qud y'r.@Nbt,. L,p.j i4 rho ded.r,nr t.,m-h/r;.tlror any slch misdectnrario! or frkdarenenl

D"b,dqt6tll+Pr"e, [^or^0IeYJ

car,c6isrcd#o=i;rpbv,rE

-?ff'jtls','^"

.,-;.. --c -:r '{

.' i' .., ,'.i: ;.,' . '.t t '' 'r

f --",lr8r,rr]l]l]!l1rj !r+f =:ffi------.*.dr"r'"!Lf !-ql:,rurll!r!l] "L"Llt" 'ar *,,:r'"' c "t

--l(\tr4

r.i1 -r

l]!19!:jrrl!!!ll

- '-1., "r-

c,'.g-. tt' '1" l"rr'

G;t;ii6,i.,,r -..r 'e'h" r'b

u,'iv.6ii\ (d |c '\j:!:sIgIL-6*te't c,t

t+

eqlrsls*d " i hr!,ryr'\ DliU'' !\ll!t

Drr!.C510? ll-1- . .

!i!!rc! !!r!c lllrll:!!r iorilo1l | +

;li; fif ri.5.dI' n'' /fl"."rtr*r.,t " tt. o

iH#;,;;i.E"li "'''" ' 'c. ! / \o $ Lr ,\,dr 'rtifd _

ffi,hur.,,rirP'+dt

iffi\ri' ili!:lr!i!!+

--,n-h".1t,,.r:q!t:19.r:!!tr:ttr++

-:Fo,i\o'tl

NAME OF THE COLLEGE

DEGLARATIoN FoRM: 20{s-r9 - FACULIY{No(e I It i5csponsiL'iliryorDei4 HoD & fa.uliy ro subntit ofl} rhe

crud doll(insasrull iimo

ardlvore,lDl AJdhr Cid

I ox.f .Uttr6'"."",14n1* 6.,*oi^*-"*, .f.!-.f vt

..ceptcd i', l-ad MCI UC/fC Ascsn,lri or sai,e

o"".r 0,"r, * rs. 0d-.03:-.1 95/is cd blGolt aurhor tic

Note.l) w,rhout fhoro lD, DcclJrrtion lorn will berr.uLr) ?) Oriainil Ccdifkres

Cedifi.atcvDocuirntVCetif ied Tiinsliiiont mud bc

l.(d)i. *-*,*.--,'-. Ptolrs^ .

1.(d)!

C.iiried.opies of p'esetdpFii,'trci( ortlc, rt P,ts.i Ntih{c *hdri

full iime /Pirr time/Honorary

..6c/r./^, I ofLq \..6. n'n /,fi,.,'

!L9<ifq-hn Mcr uc/rrc A$.snrcnr i,r rhc

0!14"

.,"".,.."^,., .a<<'^(*- )

Presenr Residenijal Addre$olempioyN:

' bLa9p"P.A-AWyD- C&Jlpl f3oos

1.(e) (b) Pernanent Residentinl Addre$ ot Enrltoyee:

Ar^.."-'

P,o . f ffvstt*a .. C-+q r rr- 6+zoo8

r (r) I l.yo l@ ufdqgono Tninirg h"Basi. Course lvorksiop, atMCI Regionat CenreinMEr ori'tlJotrc.lLgt ndetRegi.int C te obs.rauntip?

*.2

caitl / Ekcki.ny Bi /_andtine relephone Bj / Aidhar crrd/db.hed tr i pmof of cidors,Jr-6rr\Io

1.(h) co,h.rpirtntrhs:'"r 1o0,."; o 499- J&ga 90D 1,,,,nsr,,."n"1

Nam? ofIICI RcgionalCenrre whereTrainins rLas done/I/t?n'tr8 ?ds do,,cott.s4

'i!c the dct itsoftheobs.t.et

Dirc drdl'/,/.f,+ nr i ng

1.0)

r (J)

Da,eoljoi,nns p,esenr i,Eiirrtio^, oe f osb"r+ *Uth J fuE sE1R

loi',lng rcpo{ ar rlr pi?serr irniu" "t"a,.a px-fr. , I

Fo- IE-tcr ,,t'.I't( r,suDlct E aF' ilorngorr w ii.hco;y or Des'* €rri r-ici6 or MDBs;J;d i";;;",,,.l.d _ #4.copy of Rcaisriiion orMRls anu o. o"*,"" *o.n"o - f"y".Derails of drc rcachina erperiencel] dare

-n Cw"t ^nfu @!C6lbM I

Wat.

-: -]

,F,tLt, ]

lo w)\ .

t"m rerrGs

kt+^l eilot lqe]

n&#at o4lA'y. 4Lf.

yyl.Jl. iI>/

fdaa) 14 f!4u,uf'rl'te

[]o"d 3o

&'wt lo?le

I qe!

Resisrdion I Nanporrh;at i;Nowilhdaie Medi.atcoun.n

3T( NC

oq p!x, T( n<G+lM Gtlu..

.at,"u- . I

Cduqr

D\r/MCh.

ot lt?# )et pt

)G",u^l! 6r'f fA',1@0

Anpu.l6b*.) ' ' "est,^t

d:ltd,

3{h). To he filled in by E( A hy p€rennot onlla

Not€: Ihve yon b€€h .oNid@d in any UGII€ insiErior at my other iditurjon/hediFt collegeduring Ia*3 y66. lf /6/ plee give der.its.

rgq€lj*"! - -

Numberof ReJdrpubtctions

s.(.) hFrn ion.tlournil5:

5 (.) Shb/h6htuLonatJouhak:

6. (b)

MyrANctrdNoi" +-CVPR €q+e nMyAadh..-d N.. k 6tA 3q 6oss?-Ag!.

July 2(n7

(cl I have dhwn robl enolufrsb lrcn rhG co ege in the .urrent financiat year is undert

(copy or ny PAN & Form 16 ODS @dricab) ror rinanciat year 2m&17 aE dhched)

" kMdTrlr.t r an a tult rime h.h€I i'\tom -LA.M. r,o --.lL p.M. d.itv

I hdk noL pFrded nErlr b.d v orhe' M{i.at couJgE .,sr uron.D. ra(utry /RFidcnt in lnetu'rcnrd.r.iemk yer for

'hepurp@ of vct.s!rpnr.

I am not having privabe Facrie anywhere on I am pndicinS ar

xous ol pnctie are_ to _.Furdrer I srale rhar r am not doinS anyPraii; or not workins in any oL\er nospirat dudns collese hours.

Compleh debils widr regdd to wor* expadene las blgn provided & norbing hs been

ramnotworkingtumyortlermedicatollege/donhlcofiegeinrhcShlEoroub ed]eShrein any capacitr: Regular/ conta.toal/ adh(-.-Fu time / padtime / Hoi.rary.

rD" l(,k. lQo loh an wo,ki,,sm Rdfp4€.i.V i.the

'l

l'

It is d<lded rlht6ch sbteh€ni md/or ontenrs of this d<h6lior aid /or dmumenls,erd nrs \ulJm Fd iloio *ih rh. dR | 'nfon fo' n o/

'1,. u' de' 5isre; i,e .hotdFty

audleniic. In the evenr ot y sra€hent made in this dd.raiionsubs€quently tuning our to lie inoiied or f.Le dE uMe6igned has undersrood anda(epbd $at slch niedelaniion i. rcsp€ct ro any ontent of rhis de.taftrion shal atso betEaEd a a g.cs misndud thcFby rcndering rhe undeBigned tiabte for ncsarydis.iplinary a.hon (includiry Enoval orhb n.ne lrcm lndian Medi.at Regisbt.

D"h, or{ lo+ll?-PIA@J MUVA3:g!

URE 9iir+PtM

PLoYfE

ENDONSEMENT

3.

This endo!*ment is rhe .erification rhar the undersigned has satisfied hiNlf /heBefabout the coii<rne$ and vera.itv of each conrent of rhis dedaration and endoGes ihe.boven€nnoned dd.lration as brc and coried. r hrve verified rhe .enific $ / docunenrssubnir€d by the candidare vith the onsinar .efifi.aies/d(uhenb as subFttred by the.e,.herrorhe tndnuh ind wirh rhecon.e'ned rn*irurerrd hrve found rhem ro bc;nd

k. k, Rqldvl

D.,", o916tl(+

2. IalsocontirmthatDr.'s

not Pm.ricfS or carq inu our

dn) orhsd. r virv drri,.8 o[!(, worrs 5ou.'.p J.oi gIlllc.o

tn 6c ry€nt ol dlis delahtion tunrin8 out b lx e her incorNt or any parr .t rhisdeldaiid subsequendy rur trjn8 our io be iftord or lake it k !trdersi.od and a.epredtlEt the undersigned shill also be €qually rtjpoEibl€ b6id6 the iletaranr himptt/h€Eettforany such mhdelararion or mislatenent.

'6'Counlrrsigned widr sbmpby rhe

Direcror/Deatr/Pri,xipalPhc Mc|\^O6€e!

_ffiwry* 5qbnided

.;iXi:,il;1T,i:,"**u orihcs risPo* /'aN \g// Na

henrorderarPresenr

@ ,i ormenrtelr$ iI drcd n r o] oo] ui

f!// N.

ffiffiffi

5.

!9// Na

I$,/ N,

::riFffia.py .ridre-c,,rrd b".rEEue, r-*ti*;tr*H,"rs.r*".=e_

S4q ot

\q!

iti"TflJ:ilT :::t;:,1":"1 :: x::il.i")lil:i"t"ifl ;t#i,r,;Tff";' *.*''i*trdl ti1;:

';*# ;i,T-iL:; ;'Jl":."i';;1il-:il?'B ti:il:i.:,q'i;'iTall rhe rexhs5 mu+ subnir rhc rcvEcd de(hirtion rord".,;;r,i;;;.;;;;,;;:;:, ;" t;;;.:Jiiflii:'1,1il.'l"lT l:ii'J:, fl'l ill)

NAME OF THE COLLEG

DEGLARATIoN FoRM : 20{8-19 - FAGllIffNok, tneponsibilitor Dern, rroD & ta.ultt ro suimit only rhedcdrdio! loE df fidl5, who hi

cd dwolrinsarullrimc),{..€AM!1H.o.K . ..... ..

1.t) slbmirtuoroID prcornsu.(l h\ covt Arhoriii€:Photo lD submided :r'Pse&+€opyl PAN cad / *{r+ry+idh*€*d

N,-b.,..866.PR. 11+5f ........ rssued by

E- kttlz,.f ME tl]r- coit€c,r,fiN[9t rt,loztlluEl

Note 1) wnhout Photo ID, Declrdion ron lilr b€ reieded rnd -iD nd !(Lmidoicd steachina fi.ulty. 2) Origi.il Cetifi.ates rre mmdatory for iiriri.ation Allcefiri.devD(umedvcertifGd li.nslationt hu$ be in Enslish

certilied.opies of f re! rt appoinhcnt ord.r at p6ent'nditub ita.h(I

G€inffnL lojqEE?'t

Ndu.orappoi,rht d G)Res'nlat (:i*$.r{c,l /a!5{ R..'*4R(b) IiuJ ifre /E:*iae /.trffiy ru4 a rm.k) wiih or r4li{|€{i P.ivaE P6cti€ !dll!:-

D.!e or appea,an.c i', r,rt McI u.7,.7^., *n", ^*-*,q(@"

*n"n.ollege l2M/r tr\'oL.AL caL€aewhcthcr appJlred riJ ic.cptd ii I:* rvcl uc/l'C As$sfrenl n rhe samc

wnethd appeaJal UC/|C q556,menr on same

'a "E- Y(r^a'l tltotat aoltruc rnflis€lr roz<ttrtfi,ut{M

ci!: Ko2N!P@€

Wneihe! you havc rcri,cd fbh C .oiregd - Y*/ No 11 Y6,

"1-

{Jo4rAiE

,"""."-,,w

la) t'r6at Rdddhal ' YLjLIYULU l,l-A^/olYiL (ltoJtej

' 1 'f. ./dnPuj QO.N^1fi'Et('

1(eJ O) P€lfudtReidental ^ddRssof

EdPloyee:

Prtr rYurr A !4r^/ 0 rY rL (+our6 )rv. 1.7. C^44rv3 ta o)-,-4-4ji 6fn,t<o2wt(o'e -613601 , Keqtf,A

Have y@ undergone'l raining in 'Basic Coulse WorlsnoP" at MCI Regio@l CenhialrlEl or in low colk9, u't!.t Regiovl C.ntft obsetueahiPz

1.(f)

Nare ol MCI R€gional Ceik. wheE Ddk ,n l plee ot bajijrEInirnngwas d@/ tf tun'hts oas dore ireu.8e, ai@ the .letaib oJ tht ob@4

r.G)

r.(D

1.0)

ccpfif-r*t*#€+s c*d./ €tsk"lqjill /L.adli.e Heph6*B I / Aidhd c,rd /

conbd?sb(ula6 Tel(ofl e). 9

D{. N6t6i3 MA.VI\401fJ411laat, to atrlaotrkri M.otlt <P!t 4 ied'1t totrtuo'wE< Rtn€'r. 6ort

^ @t.nd)E\a

F r.,.t tddr6<: JJt44 +btQ:!!!!:!4 I.oe

D,e of jo,ninsp€grm{id n 11-a6-)ol

Joinins Gpod at the ps?nt insritue ae.hed - Y6/!J6

t1o2$v6E-613&)l

x h9st'.h{J oftsloq

eota

Note For ?G'Pon Pc qnalilicah.n addihoml Rqkrari.n .e.riticaie particutaN be furnishcd andsubj{i be aftd roring our n4ri.hevd s nor applicable

2. (a ) copy ol Desree certiticat* of MBBS and pc deF@ rnrhed , J/erAi+

2. (b ) copy of Resisrrrion of MBBS fd Pc degrm dbch€d - y:zr1Jt

3 (a). Dehik of ihe rea.hins expcricn.c hll dab

g-6-ada1

ry

N;;;it- ff";l-r--r. l rd-DDAtNt /Y DD,4rtNr/t t, Frpsicn(

(E )o1 at-o+ao'n \4@@'Ioz\n.4kfili. ^.atLtL .a.o1 16ta a747 aat 1 qi4"!:!!!Y)

iffi,{i&tr at-a-aar7 &""*4;;; 16 4elt

sd{.q€tY

+f

Noter Tltor / Residenr working inexperien.e in the r6p*tirc.oruider as senior residenr.

dd Radicdiagncis nu* have 3 years reachingin a re.ognized/permifted nedi.al in{iirreto be

v+911

3+911

L

Tobe rirled in b' E\ Am' r.Eonn€l only:

Nore Have you be€n oreidercdduring lat 3 years Itt6,

i', inr UG/PC insp{tion at any oder inshbtion/nedical collcgc

B€roE Joinins pr*nt iN{ urion r ws }o ing d414r9duota@1d4ff+!rd4oq *A9JUrtu{ r&or.<.4 and relieved on l6-o6-ao4 afie.

c*n4 / reiiin3 /Tdrsfering (Retievins order is endoFd fiofr thc prcvious

Nunberot Researchpubli.iiionsintnds Jounals, -Tht,

< ,"r 'r e,nrbort oun . .N,N,-"s!"* frru;;;;,

5 ftVr.idtror.l ouraLoar .n6&I4rJ!r&_llsarl!d: t!t! d rq{,

.u, 16 d 4y-: d ruii.,fr,.t.r.l.r tt Dr. rtor.dd -r4'+td,ttja3+/ n5 or, ad tMy PAN cad No. b _3a6 PR ?1+5 :iMyAadhdcdNo.is ?6t4r1a2l1l{l I

I hare drawn robl€mollmdd$ nofr dxs coll.gc in rh?curEnili.ancialyearas unJcr-

)4000

3,

5,

6. G ) (copy ol my lAN & Iom 16 OD6 erbJidE) tor ri..ftial t€r 201&17 ae attached)

Dle!4B^Ilgli

^3Jo(JA€ '{Onr(o8 in dre

Depdher of 6dcak !I|46EAY at

,r€t !rr.o rlEtrn r,n- @r& @r€ in rhe ci9 of 4AU(d' md m

College md do hd€hy gNe an mddbking

6e^,E(fiL !u46dY . working rron --LAj!d b 4-PM.dailv

I hav€ rct rMEd Fysclt ro any odrr Medi.al Collqe / lNntudon a a f&ultv /R6idat in rhe cuEeni aede'nic yed for dre Purpose of MCI atffi€nr'I-6=.*-l*bS--"rittt€--PfrE +syt!!.€ OR I d Prdlc'ry ar

hor of p'&t@ aE---5te b t?- F".$d I "hF

that I * not doi'8 'nv

Privab

Pr&d€ or mt workinS in any orhet hosPital dudng oleSe houd

Conplele det iL vilh Egnrd ro work dFrieme hG b@n Fdovtded & notl63 hd bd

i .- "* -,i'ue in ov .rt'* meaical rcU€se/ dmbl ollese in rhe slah or outside DP sbEn dy oFcity: F€suL; / contr. tu.| / Adhtr -- rull b me / Parr td' / tlomr'ry'

li i. d4lar€d rh.t 4h sbencnt and/oi contenb of this d{l*ation od /or dcunents'cerrifidt6 subnltl€d along stth &e delaration form, bv the undeBigned tre ahd'luiely

h€, cond and rurhenrr n rhe dert o' any sbbhent m'de 'n

lii' d*liratiosubs<endv h,rms oul b b. ,notKr d la|!. d* undeDigned hs undeFbod rnd

^ed;d 'n;r $ch dids l"nhon in rBpd b .nv <o+nt ot ini' deddEtion tn'rr ab b

b;:d 6. @$ MndFr dT€bv rendmng tM ud*isned hib'e fo' n'sfldiFplin.ty .(ion (tndudins Fmoval ot l$ nane frcm lndid Vedlcal Re8nE)

Dde o4lc{lt

r, Di aAY1esR l'{

SIGNATURE O! THE EMPTOYEE

r. thn endoreemenr h rhe {('h .arion dmr rhe uddeNsned has saiisfied hin!,r /hc6.tfofcich.onrcnroi rhis dectrriti.n and endorces iheab.ve

nentiorEd de.laration as ttrr and .oiied I hive vedfied rhe reiti6.ares / do(unenhsrbhitted by thec ,ridal. sirh the oliginal.edifi. €sldo.uments aseubmihcd by ther€acher ro the In6rituie and wiih rhe .on.eh.d rnstirute md have folnd then io be.ortect and authenii..

2. ralso.onJirm $at Dr. _RAMel! tPt( is nor pr..h.ins or carvi,rs .danyorhe.a.dlity durins dlqtg wdkrs homs ie rrom _4se b

3 In the evenr of dir dttarahon tuning oui b be ei$er i.cor*i or any pan ot $kddafthon subs€quendy run'n,g oui io bc incorcior Iake it is undeGted and ac.epredihai fie u.delsigned shaI itso he €qua11y respo6ibte t$idcs rhcdNtarinr hinuelf/he6dtfrord) such mEd&lardrn tr n,\brmenr.

.",.".,,,,"0y'ffi".,,.Dnedor/r\an/rrrncjBrt

*al

D"b,o l+lo ?\l?

!.1!oRAut P6p.n sir phoro of ihe Enploy€, Signed by Dean /PrinciFl .l dE .o esePhob lD prool isued br a,r 1 Au thfLh* !:s?*/ p Ncard / \rokirD / Ardbrr:l{ic.rhficdcopia of presenr,f poinhentordcrar p€enl

copy of Rs?e4 /v!*t*l / Fr-n-ill, R,rr / &&*.ft+il]/ Aadhar card / n4*-rrirft. rft atra.hed is a pioor orpresentrcsidcn.ccopy of Pr!rped/v&+r:i+tr / xLi';r !, Rrn / l.re91*€sirl/ Aadhar card ara.hed d ,t p'oof of Fnnaneni psiden.e

toin ilr repvrat rhe pr.sc' L ,iitob.(op,esol Derqrp erh f,(i fA , I MBBSrnd rcd.F@.copisornegrshabon ol MBr'5:nd rcdeir€copy ol erpeiien.e.erhrndc tor all tea.hi'rgappoinimentshcld betore ioi,rins pre.enr i,riitoicR<heqnsordertom

'he rr$ vu\ n(htuhon

Forn r6 fmslerhr (aF) o] fleldrrinanlia yedrlxierh€ad (in.:se.l6.i h.r\ $ hoir pndtrLns)Coo\ oI u C r&osnE.r r.. {ledd tumarr,litcd

-l

Sid.d 6v rhe Teah€.Dc!e{r+ \oq li.f

1un-Si€ned bv the HOD:P4e!oqtdlt+

K.n-c1PriiciPal

si@.t & vqified bv th€ A$essor :

D!!c r

NAIE

1. The De.Idatld Fom will nd be a.eptet and ihe peBon wilt noi be @ntd r t..cher irDy or rh€ above .tenmrs .rc noi enclo*d / alt..hed wiri rhe D€.trratton Fom,z Th. pssn will nd be.ounred d- I rp:(her lf rhe diFnal of Phdo tD proor, R€gBh.tidc.ni6cde' / DeFe .enificrte! / PAN crd / srarc M.di.j colmi I tD {if krued) re ndprcdred for v€dfi..tion d rhe rine of 6eesnd,

3. Ail the t€achdr mEt s{bnir rhe wi*d d*ta{ion forn in rhl3 f6at only. (Anydeldarion lon slbniftd tn an old lornlr will not be .(ept€d .nd ie will not be .ounba

Copy of PG. @gnized r.mUruv@iv.dorP.C A$a$mc

NAME OF THE COLLEGEI cl

DEGLARATIoN FoRM: 2018-19 - FACULTY0,,rors: Itisrcsponsibilityor Doi4 HoD &Ia lty to subDir only rhedediratiotr rom of frculty *hd hr

othd collesc <luang rhe imdcn,i. ye* ind workio€ ij rull tin'.)

| (!) \.n. . .^/:J.4uort

Dale orBnrh & Ase .. 9-t111/ 1.,-P-...11

1.(.) slbn tPhoto lD prooti$ued byGovt. AurhoritigPhofo IO srbnritr.d :

Paespot.opy/PAN card/voter IDlAidhii cird

N..r,.,......f.r.Y.. ..'2

Norq 1) wirhour rhoto Iq De(laratioh lorfr Fillfaculty. z) Orlainrl Cedifi.rrcs

C€nificrrevDku cntvcenifiedTrmsldions, mun

1.(d)i.

1.(d)iii.

1(d) u

r.(d)viii

.c.h'.l.ope..lp'.."' dppoi'.rqdo' l

Nature or appoinhenl (i){b)G)

Resiili' / cdrnadtril /Adho.&x tinre /Pii ti e/Hoionryyxh o, w rhour P

'virel,,i.rccDrre orappernn.r nr Lr* Mcr - uc/Pc/A.y od,e. Ars$-oi 61!{8'. -hnh6\e.e ptL.t t4clrtth raLL\e.wnether appeared rnd ac.epted nr rn* MCI UC/PC Ase$D,enr i'r rhe same

l^h{\-' ..opF..'"c )4 r.Fpnc\ r'1.... v I - uc t\c c$,..tr 1. .{ di..whcther you halc rct(cd tron 6o!crm!f( ncdi.n ..11.3. rcsDsisn{ion r/ 4

1.(e) Preent R6idential Add66 of emplore

!te,.r\t, ttlKt

Plebt6l- (a.Le\., (7taot

(b) Perm.nerr R6dentiai Ad.lre$ olEnployee :

rtaar<aturrq G,,t

6795a+

1.(0 Haveyou undergoneTiainingin'Basi.CourseWorkhop atMCI RqionalCcnrrca MEf or hl Votr @llege udet Re9ior.t ctttre orserua6h4'?

Yes E *.2

loi^ingrepoiat$eprcsenr i$ht,**o*t - /V*"

1. (9

1. (h)

1. (D

r.o

Copy of Pissport/Voter Card / Elefticfty Bitt

^ddtine T€l?phone B I / Aidh Card /

attached as a pr6f of reside!.e YeVNo

conbcrpa,hcuia,(: r-r(o,ri.C olf:{---j!4rrt!

a1r.f d, @ I *;J .'q

7s1t tt, r1tDar€ ofFjnins pr6cd instjruuon. o

' l't lz"t

Naft ol MCI Regionar Celne whereTmitin4vds d.ftl IJ tni"t,tg@t dotu nletbg.,at@dt detaiL ofrhe obsetuel

Da re ,d /lr.P oI Fa inbg

hsstsf,ei r4orctsL

Nore For PG-Po* IrG qualilication addftiofar Relkkation .erificaie paii.uta.s b€ runrishcd indsubjst beafters.oriig out r'hi.trever n norappli.abte

2.(a) copyorDesr€e.edri.ires orMBBS d Pc deseeirriched -YcVNo

2.'br Lopvornes.ir'r ionurMsBs.md PL derFr rhcd - YacVNo

I (a). Dchilsofrhc bic r iDe\peren(e hlldire.

wo*ing in Anesrhcsi: andrespectivedcP nFntsini

3 52tr

subriet .31{14

aSalt

DM/M Ch. ,,t

3

",.(::.,:.t

4dqcN

qu,.o[Y.]

l1M q.i M€d\

Co|'|3qor

.on5id.r r, senior reiidcnr.

3O), To be fill€d in by Er aJmy PeEonn€l only:

2:

3.

Noie Have yor ben costdercd

duringl6t3y6G. Iy6,in ant UG/PG iNpeuon at ary olfie. instibrtion/nedical .ollqe

ho't: 't.nl(rL '!'(r"s€ro,€ ioinin! bJ.enr i,stitorion I wis worrinz dr tta!^a--eaara ctL"'6^

J;r,"i retqae( *a "r"","a -@-",

Eignjng /'Eriring /TraNGring (Reti@ins orde! is ercl;sed rrcm th€ Fevlols

6. {.) Mr IANc.d No. is

6. O) My A.dhrr card No. B

Numb€r of Rffir.h publiGrioro in rnds tournaG:

5 (.) InFm.tionarn-n.rs,--Ftr.1--r-u1a ptu-E; .i J^ -fs.rbl Nariorrlroumrk z &drlrL '- .i l-- E ah, ,..; r\, 's.(c) sta,€/rnstitutiona,routu"9sfey4*L% + c eTW

o.G) I havedrqf toblemo rmears riom tnj,o'%e in tlccu(nrr'nrrcialyerrrsurdcF

(rtqL6gc?t

6, G ) (coPy ol hy sAN & rom 16 (IDs €rtficaF) for hnarc'.| yar 201617 .e .rhch4d)

am wor&ilg as Agocr.'F

L

7.

L

Depaihnd\r or _.1r9!c34_-!1alry_ dCollqe and do hereby giv€ an nndenaking tlEt I io a aull rimc rcichcr inOOi: rp qeue\nL sqAheEl *o,r.i"g r--_L,r.rt o anrtaoiry

I haw .oi pGenred nyselt b my other Medical College / lNt utionReident in the.urrent a.ademic yerr for the purpM of MCI assnetrt.r am nor h.uine Ev.'e pm.'jB .,ywreF on I anKl$ tb.lV4 in dE ciry of laopvva.r'-"

"r p*ri* *"-!!a t" lll-Furthe, i shr€ rhat r am not doing any

Prrtie or nor working in any odEr lDspirrl durinS ouege hou*.

Condeb d€r.ils with rqnrd b worl eiperience has ben povided & norhing has tlen

5 Iam notworkirg ihanyother nredical€llege/de al.ollege in theShborouaide th€sbhinanycap.lcny:ResuLr/corhactual/ Adhoc,-rull lim€/Pa rine/Honorary.

6. k is d*l.red thit each slalement andlor contenrs of rhis ddaration and /or dduhenb,€*ificates submitred along with ihe d(laration fornr by the unde6igned a€ absolur€lyrue. corKt and aurhentic. In the evenr of arv srireoent made in thk dslaniionsnbd€qu€nrly turning out to h€ in.orier or lale the und€6i3n€d has undeBtmd anda@p€d lhatslch nGddaration in r6p€cr to any.onknt of this dda'ation shillal$ behEd 6 a Arc$ nisonduct rhePby rendsi,rg rhe undcrsigne,l liible for R6sarydisipliDry achon (including Enoval of hE name tom Indi.n Medical liegGE4.

'nris endoEment is rhe certificrtion ihrt the lndercigned has satisfied hinNell /hcEcltabout rhe conehe$ and ve..city of sch .ontent of rhk decl.ration .nd eido.s the abovcm€.rion d delaration as true and orre.L I have verified the.e*ifkates/ do.uoenrssubnited bt th. cddidate with rh. oneinal cerdfi€t€ydo.unenrs is subnitted bt ihere{hs ro ihe ttuiibr. and wnh rhe .on.er.ed Instinft .nd h.vo found rhe'n ro be .oded

2. I also.o trn rh.tDr. n notPF.h.inSor.iryinsour

nny orh.r a.rjvity durins orrese wo'kii8 rD!6 i.e. non g:1 b -gla sinc r€/she

hd joined lhe lnstitu!e.

3. In the evenr of this declantion tumiry out io be either incore.r or any pai of thisddantion subsequenily tudng out ro ba in onftt or tal* it is nndercbon and ac.€pr€ddht the undedign€d sh.ll .lso be equ.lly epoNible besides thc declarant hinself/henell60r any such misdelarationo' nisst tement.4

Counte6igned with dampby thcDn*br/Dean/Pri"cip.l

NAME OF THE GOLLEGE: K

DEcLARATIoN FoRM: 2O1e'r9 - FAGULTY(Nore : rr is dPonsibirftr of Dei[,ddlidrio.to;r orlaotty *hohrs not aPPelnd for Kesncnt inJnv

oth.r.olleaed!r;nsrhe icadeni.yerirrdsorkinc!srurr tiDr.)

r.F) \,. o Df a,..B^LA!:l

1.(!) Dare oI Bid, & Age ..az:p..1: /-9.}7

l.(.) sub'n tPhoro lDproor $(. ttCovr Author ri.slPhotorD subniiied: ,7 EdflrJ$poi (oPyl rAN Cr'o/ \ or.r lD/

^rd ri (. rd v'

N'^b., 814.8 .e€l7...?4 lo . ksr.lbv u!1144! 1€rQtnlt9N'atlt*o't * tut"t

Nore 1) wfihout thoro lO, Dedariuon fo'n Lvill bc rci.ocd ind will not be considcr'd is*.r.i.q .J.ul,y 2, OriS'nrl i 4r f..{es rrc m,ldiror) _or c(ir'rr'io' Al

cedir';hvoo(ui,pdJLof I dl r.rFl" or' run be ir I n8l'h

Pecd Dsis.dioi -o1!11 (d) i.

1.(d)ii.

Ceiilied.opies of p'cscnt ipPoirhnent oder r PL?scnt ii$hturP th'hRi

n.I rnr.: r,ar:f3l _--r 1-1- \ 4. r ML^t.aL ULLEdF

1.(d)vi.

1.(d)rii

Natopofiplsi'rrnrenL (i) Restrl / corh&tuaLl^dhF BtaLll(b)Fullti'ne/Parttinrc/ll.mmrv F4'L'14(cl wfth or wirhou t P, iraie ha.ti.e--ttzptL

Darc oI app€a'in.e ir rid Nlcl - u"1*1^"y.,*- o**"..,, ot h(0, -r,nl'cot]Leae,k!$a :a4CA!44 e!! 1E "Elvheih.r appeaied Nl accePted nr Lasl MCI - UC,l|€ A$cs'nent i1 rlrc samc

whcrher appeircd a.d rePtcd iir hd MCI - uc/fe Asse$iieit on sanrc

Desi!naiion - \.*lNolvhJhc' you havc ie.nld rroDr cole.rment mcdicil ..llesc -+e / No II Ycs

DosigNrion

,/^

1.G) F) Pqmandlr Rsidcnhar

4:1Lt 1/

k4ttahalv6tALAu v/4

1(t undergonoTlii,rnrgnr "Bastc Con6e WorkshoP" al MCIot tpn tolltgt ula Regionnl cNrt'a ohsear'shiP1

lcltResdercg o!4t'1lr2 J

a (c)

r-ane of MCI ltegional CentP rvnero

Toining Nas dond/Ilrntn,aruds dotrz

colteg., Site th. dehits oJ tht obselaet

lD te n'li/'l',n ollriininli

copydrPaspot/^r'oftrc d/Eledrkitv6illArndlinel.t€phoncsirl/^adhtlicJd/attached rs i proolof rcsnlen.c Ycve+a

Co' hcrrrr.u "E Te (Oin.c):

E nttad,na, tLa)44 115L3 !:a!

n"r"oirou..sp,*"ut rrrtrtor oq o! 20l21.0)

1.(i) Joini'rg reportrr thcpBeotinstitutritrchcd - YA/N&

Fo!PG'PodBiqualifi.ahonrdditionalReglstation.e4lllratcPirti'L'latsbcfLtrni5hedaNlsubi€r bcafrerscoringo!r whichever k notaPPlicable

cdyofDegieeccnificat.s or N{l}Bs and Pc desrcc dta.h.d - Yey'Nd

Copy ol R.SiskrtionofMBBS a'rd !G degrcc ati.hed - Yet6{

Detailsof the leachngerpe ence hlldrle

'l

I

Nd+ ruror/ R6"l€nr sorrihB nretpeden.e in rh. rcspedi{e

MBBS

tor02

uol'%roNu

'tl?L'z

JuniorResideni

c'^ rA,t ollc+ilorl c'r'oq8

Tob€ rilled ii bJ E\ Arn,) fcDonnqlontyl

Note l{i!c ror tr..tr.oN e.ed

duri'rg l.si :l ydft Itres,

irrn!otr. $ituthr/De.{i$ .oth8.

sclorc jonriis preseni jlsturion I ws rrrkig d keR&t Updl tl.sr{ S.An.tS E?ar$ord fle\ed .n ao- ;r r- 6

rs€*4 / rehrnr8 / I€*Je*i|8 (rkticvirs oider is crctose,l rio,n rhe prcviotrs

5. N, mtrrof rtairlr Pu, .iri s

5 { ) hr0, rion loun .

5 G) Shrr/rEhhiiornlo ri.,r\:

LG) M)l,\NcrnNoi5 4jr)6, A 3al4 J-

6. (b) Mr Aidh or.l No is

i F;; T -'T.

I

5, (c) IhavedF,n robtodunenbhdm tiieorres€jn rtrecliie,rrinan.iatymrs under:

TDS

66.+ ar L 4oo66r{31 tJSd

6. (c ) (Copy ot my ?AN & Fo.m 16 OD6 ertilidle) tor tinancia! rqr 2016t7 aE atra.hed)

DECLARATlON

D.p*6*,1 .r@B!!t! lgqc4L dt K.M.z 7

Collea".nd do he'eb, gtre M unde'rat'ng rt,i tan. fufl tim€ hchn n*o*hg r.o-l&_A.M. b l+ pM. d"ily

I h.ve rcl p,Mbd myse I lo any orher ved cat cotLg., r*u*no. * "'.-r,y rRdidentin the cu rdr .mdemk yer Io' $e p.'rpse orMCir\srmenr.I u not having privare piacice anywh€re oR I am pracrj.ing ar

nours or prrn@ are_ b _.Further I shre thnt I am not doinS any

5,

Pracdc o! not worknrg in ay othe! hcpnal durhg @ttege hour.

Conplete.tetails wirh rqald t' vorl experienc h.s been provid.rl & norhing has b.ar

I am nol wo*in8 jn tu1y other nedical collegc/denral o ege ih rtre sribe or oubjd€ rhe sraEin any .aFcity: ReBular / conthcul / Adhoc -- Futt time / parl tim. / Honora*.

I

It is de.lired rhat ea.h ditcD,.nt and/o, .ontcnb oI this d(i,ittun iirl /or (l(trn.nts,ceLhlnaks suLrn,itted ilorg \ ih dre llediraion Ln, hy tl'e trn(i.r!g&d ift iL)nt'tel'ttre .orr{t and iudrdti. ln the e'etrr ot .,ry drtei,etrrslbseqmDtly t!n,i'rg out to bc imoflcd or raGc rhc undcrigncd hrs unncrstood rnda(cptcd rhats,.h nrisdKlirntd, in

'cs!..t to rnl.ontert.f this dedir,,hon shillilso bc

teded as a gro$ his..ddud rhepby rendernrg rhe ! e,signeddk.lpl rar),a.rion(i'rludii! rDovilothisn etoi, lrrliir \1(n.al lrqtisrft

^1?Lo*, oglc+ lrL

sICN.\TURE OTTHE EMfIO\ !I;

Thr erdorsenrnr isrlrceirif.[io,rhitt)eu l!'rirrdrJ ll5 nLd h nrlr/ho5.riL,out rlE..reche$ anl ya,irlq .flrrh rorcntol rL,ir dr.lrirn'lmenrioned dcdararion ff trc r]d corrcd I hrvc vclifiod th. ccnificdes/ docuncntssrbnitr€d by rhecmdidarc lvith iheoriginal.enificrtevdocunrent * submitted bt thrt.rcherrotl'e Institute hd rvilh t

T edlo.^ n r f P,i.i.ir gi,,in rs! r

.i.o,tr...f..1d., u.,r", u , €4.' q4,,,'

h the elcnt ol rlns dcdirrhon tun$ out io L! c,tho! i(oc!dNliniior subscquein! hii,'lj tr,deEioo.l adll r.sthlldut tlre urdd6itiedshillalro Leequallt'

'espo.sibls besdps (hed.dar^rt himdr/heN I

ror i,'J nL.h ,nisde.lrntioi o m shte'nerr

D,t. o5l.+ll? .,,,,".-,". -'dr".,. !)i.do /r)c /frn.iPr,

a

5.1!o1. R6ent Pa$Fo( si2e photo of dre En,ploye, Slgned bl, D€ /

Phoio ID p.oof i$ued by Govi Aurho'ih$ Pisspoi / I,ANcardlvoterID/

^adharcardCcrhfied copies of pitscnt ipponrhncntordcrit present

copy ofP.sp.itlvorer cnrt1/ Er.d,i.ilr 8ir / r'cre0hoN Bitl/

^.dharcard / Deai sallorneril.LGr atta.hcd isi po!r ol

)y/ No

Copl, of Pa$p.d /voier Ci ai / El{rkiry Rill/ Telephom Bill/ a.rhar card atacl,ed.s a proolol pe,,naneitresnreNe.Joi'iins'cport at ilrc prcscit itrditut..

Copcsof fcachihonof rlb35r l{.rcsrc..Copy orex*neftece'ht,.ate fofallt i.h rg rppoi,tmosheld L€fore ioi,ri'r,l plesen1 lNituteRe evi',rorder iro

Form 16 tfDslediti.i'e) ror rhe xfr ! ri reiiIxrrcrhcnr( r osc^f kTrcr. \ho r ! e,i.r. a)Copy ofUG resgrize(t tei.her lere. f oo irfiliited

Copy of P.C. r€ogniTf, tidrerlett., rronirnlidUnive6tr.(ro' Pc. As$svneno

9rcE! !tr!!&!!!cLP3&.! 5.1, t?

{. --cou nre6,sned wir h aimp {i d'ltrltr rdlio rl:

D!!q 06LotlR ri r'.cI "::'.'r- L:'t.J

Siened &veriried bv lhc A$essor:

!q!!-i

The Declardion Forn rfill not Lrc a...ptcd rnd the peison ryilr nanyoltheibove do.ufrenrs are nlotendosed/ilta.hed sIh rhe De.l'ration Forn.Thc pe6on nill not be counted ie i t.adror ir the oiginrl or Photo lD proo, Regiskdionceiificat?s/ Dcgree ccitifi.*es/ PAN Cir.l/ State Medical Coun.il ID (if isoed) & norprcduced lor vcrif iciion * th. tin,e of rsscslned.

uuf subnrir ihe Fvised dedai ion for6 in this fornit onlt. ( nydedarition forn subn ttud nian old lonnrt $illnot beacccptcd rnd hewill not bc.ounrcd

NAME OF THE CoLLEGE: K^1IT ('f' earuL, (ov,e1"6.

D eofA$esshenr

{Norer jtisn!pdnsibilir} ot D.in, rroD & fa.utry ro 3uborir onryrhedrtlaGiion fomof fituky wtro tDs mr appered forrsc$ir.ntnr rtry

drhe.(olhscdudrgrlE iodcnicyri!rnd wolkinsrs tu riE)

rl")^",.".....'.rnf

I F hry?r.(b) Dii,rI'rri&^s!

1.(.) SubmitPho$ ID prooths!ed hy Corr ]\rrhorir.sPhotoiDn'Lrn red:Psspdr oPy/ ty cir.r / vokr

N"-1",.4RI44 6?44 4 .. -*u o,

Note r) l{irhdr PImb rD, D!.hnrion ron witi be rejedcd r* *i|' *' * *.{i.:."0 ,"tei.tuns h.urry. 2) orisinrt ccdilicills a.e mijrdaroo, for lciri(ailon. ^trCertif icdet/Docmrcnrycerrif ied Tnnxlarjons, nrun bc in Engtish

l.(d)iv

p*** D*rs-** .4 t6,daN,r p{o p€rt"d-fulsitPresei i.r |

'ci ',!h4

K/'q c.r 44 q,or(+c_ Cwet e

L{f.L,rr r corr.,,r7 4th"l(b) iiurrli,r6 /Pi tiinc/HdD,irr()t\ir u \\'rloL I f \irc fLilr.r

collcsc l{trr\{frMrr. Le/,rciri, orrg -,,.,*, or[olrp,.'",

DEcLARATIoN FoRM: 2018-{e - FACULTY

2"?tl9\ENEBJL-

1(r)vi

,l{lrttlu aPPeiied a ic.ePred IrI\t MC LC/IG A$si c n

J"c/N.u harc rcri,c.{ rroni cov.Ln ror mc(li.,rl . c8c , yes ,/ \o ri y.\,

l4Lt cu.l:)

r*^*"- *.,^ Z, "a-4-

1{e ) lrgent Reeidenhal Add6of emPloye:

9+Fl 4lu'+lrie4 '!taK.{^L{ cnP-t\a*L< l:!\!!

6-9 +-z-o)1{t4K4

1.(e) (b) P€manent R6dential A'ld res oI Emplovee :

LAL| t_"Jj- .

cr" . al}-<'tl Q roNr+L. rhtDlaaL- ha.-L ,

r.{D

1. (q

1(i)

:- Xs^ro f}hgl &414 \3

Have lou und',gone I'iioirgin Bai\ 'oJD"

worl5hoP at vcl Regton'l c0ntF

h Met ot n' !1* .ottry? rhtct R?gio@t c'ttu obsatueDhiP:

Yes I Nol I

Coovof fr$pot^olerC''d/ lled'ki$ BillA'ndl:ne IelephonP Bill/ardhrrCard/ih;hed sJ ir@rorRsidotre YaNo

conh.r P.ft(ula6: .aiou*") -?ll

8"",,.,,,d*,. t\"ti4r",.d rs,€)f,,"\- i 4--

".b, " N,-r,". "qF(Yr lt-}$u

1. {s)

1- O)

DaE;r joinins p@nt Lnnirrbon lq 2el

DJtenrdp/n.r ol hainingNatr or MCt RegDnJIcenEe where

IerM4was d6e/ Il r$innA was done il.o114c,4!. ttte dchits of the obtetucl

lominspporrd$ePr6enri'6titoFdh.hed-)./No .

* ,459ult$?9P.

kh.to,^r c . llkfll

9 6sa4

{u'} tfnac C.l'.."r1 lcu k5MD/)r5lDNB

3 (a). Dehils o! the c{lring expdicNe till dde

A-eihsh ind n,di.rqhg-,tr -*t

fii;r E.F,i"*.i.

rt. 8.,9 r{.8. hr4

T[rddeo'(qlu.'*.U,,y,r

r-,-''$"t1

-t

Nore H.v! r-ou b*n..o!(re,en

dtrr,g li{3 ft,rL Lr).s,

Tobe r lle,lin by L' ^nn)

l.bonnclo' ):

v.drer ii*rhrnon/ cltr..n.oL.g.

8ef.,, rotr rlp,€r ' ' , rL o, I

t4\tor kcq4!44.q^.{( ( qlr4J-

d;;larr.Er4 .11!.RilL'ins / dni[ /T,i]f.r i,rs tRcricvirg

Nr Leroi .$!,, l t trLr I Li

r.t) rr! Ln li! l

-5.lbr irhof o rfrs l

i (.) sLk/r,\hfuf i, rl.,,r\_:

.4Prro Q!44 o.

! rbr Ni, ,nJh ., | .o r-3q3 31!r43ql

(c) lhivcdn,enrohlcilo uDeirslrorn thh.otl+e i' trrc.u..f I ri.inrciristr .r

0

looo

6.(c){copy.IilrPAN&Foinrr6ftDs.c*iri.are)r. rnancrit),err1016r7rrcari ..t)

1.D,. ,k+?t ^A\a

A9--, "-kfs * 4E rr4$rftr:e€1j,?hDeFd.d.r L,/hzell >v/f? ft ki{r,r P\.J,rAr q|rm"dr."r

colle3e aid do hercby Eive irnde.lalii,,* ilrtt I im a lutt tin. ieachc' in

*" r,,u r,..Lr rr -ta pNr.J, J

hdB of pricticc r1.- b rtr'therl nde thar I dn iol.ioDg irJ, p' \,rrrInctke or not !vorking i'r anl, odrrf hospital Lltrri,,g.oilog. hours

coi,rneG {leri, s N dr .cgr(l b No,k erpa,i!..e hI hcr,rrov d.. ar Mril ,lr his luiI rn notlorking ir rnt otlrcr nlili.)l..ll€ue/denr.Lrc lctlc jr rtresbreoroubmc drcsrar.inanr.apa.itl R%rh/ c.d.a.r[il/

^dlro. ftrl]'i'nc/ Pii rime / Honoriry

i nava not plesentud myselr to rtrl orlrrRsid.nr ir r[e ur?n1 a.]dedr( yo for rhc

r iDr not htrri']8 Pr 'Ie rFdire

v*l(al collcsi / rrxrirtrii., is i tiNtt /PtripG! or Nrcr irsessncnr

dlyqh.re oR i rm Pmdt.iiS iri,r flrrirt ol _ r dn

-'t

D^,,t'tbltr roL n e6 D)e0 L,rh ni ip !f,tr!Di,e.ror/Dean/rrimipal

ll is dsrr.ed drar cach srar.menr and/or con(ctrb ot rhh dectar?iiof an.l /or d.runrcns,ccrtili.rtes srbnnhd ikuu Nirh dF dedarari.i fon, bt rrc trndoN$rert ir. ibsoh rdr

atrrhlrii. I'r dre cvcnr ol ary *itumcrr n[d. i,r rri\ d(imtione'bsequsndy ru'ni'rg out ro be in.oftd or rilse rhe rndesiSncd has undp^rx ra(epied drtsu.h misdelrrdion in resped Lo aiy onenr of rhis decladriotr shi|.nso bctredeJAigresmisond(rrluab),rcndcrirl3llje(n]eh3n!idiscipri,raryacrion (n\ctudnrg icmovalotlra M,nc f.om t,rdi.r Medi.it Regisref).

Plie mal1Al9?

D",", oq{1{t+slcNAru2rl Hri rMPLoYr!

)r"9e"'

TlrE cndo,scnonr js rhe .erirkarion rlrar d'e trfdc6j3r.d har riiisfie(t hi,nse /hds. r

about ilrcco'rctre$ rnl rera. ir olea.hrorroiiot this n.dirinnr '.n(t

erJorN rtr. iL{\cn'edtioned dcdaration rs rtre rll (oncd. I hrve verified rtrc.enjri.aies/do.umcfbsubnitrcd by rhe.a.diditc *irh ihc origitr:lcerrifkitettlotune.b is subnj ed by iheretrchertothe In$nuic md $ithrheconce.rd lniirieinrthavefound rhen io be.omd

'')!1 4\g!:'' ' B'aa aq

ln rlrc clcir oI ihj5 (lKl,rririotr trlniig out ro Lr. .irft. ororcn or inr p;n of rtn!.ldi.ntion suL,scqucrrly lu'ri'rg out io be imorr.r or Ii sr ir is trnde6nJod iid a..eprldthd dre rndorigned srDrl ir$o tr alurlly rcspoNibteberncs rhc.tedara hLmscttherse IL' ady sudi m6d(larrtion.f irirsite'nenr

trfrnit* fg+-',r

c-,"-""n.,r " i.r. *,.0 L,' u-6G-,*u"Ls&i 06101/l?.... "- I . ...|:.csiened & va.ified hv rtrc /\sc$orl&&-l

\.ar! i

The Dedaration rbrm will not be i(.e!red ind rhe p{ron nill nor bc.ounred is rei.hs tfanyofthernove docunrcnb arc nlor cndosed/ath.lied wirh rhe Dedrttion [ornrThe p4!,n ryill not bc cornred rs a rca.rer if rh. oagin.t .r Plnr. tD proot, RegGr$joDccdificils / D%reo ceirifjcdes / PAN card / srir Ntedkat corm.ir 1D (if i.sued) rc nd

I

p.od'tP r o, \P,'i(iior.irt'3. AII rhe r.r.hets i€lned dc.lrnrion fonn nr .hh fo onty. (^D)

d*hrition forDr submilre,r ir id old tor n* Bill nor bc rrt€prdJ ind hc wtit nor be n,unrtd

NTNIANKS

R..etrtPaspo,ts /e thoro oaihetr,npt.!.., sign.d bf Dcai /rhorolDprcorrsn'.(l btcorr ALd'oriiics:passpo,r / p^Ncard/ voLe,lD/

^. rrrc,rrd

cedifie .oti.\ ol present appojrrhnetrtordcrar pr.$dl

Copv ofPsspo(/vorerCrrd / Elcd, i.jly Rjrt/ Tetephone Bi/

^adlri, cafd/ De.nisiIohrenr .tror:rrche(tisi frooaof

4G) copt,orPi!\fod/Vore'c.rd/Ele$(iitllill/ rer.phonaRirl/ i\idharcrd xriachcd is i pfool.l re0. 'e( res (lcr.!

13',Po,tr ilcl, r! n $fturc.,. irD"gr...o'Lf.ire, ol rjBr.S r d t{].l!6 !!e,pTPertrhirlro MLrLls,

' d rc !,! ?e

copl or.rp.,ier.e lenifi(dc to' all re,rLii,rf.rp$ nD. G yoi / x.lrckl tnfor ioiiifu, !,.se i'liirtric&Lct rrd o' I u no

r9rr16(rDi.rr, 4r, i!t,,tr .r r!'LJlqhn4 l,,t.in oi re. Lr5r,hir I I' d rtr s)copv ol uc dognizcd icicher 1.tr., f,onrifli iircd

Copy of PC. r.ognrz..r r... \r ter* froDr ifaitiarcdunrv.riry (of P.c

^$ernr!Ai)

Yes / No

NAME OF THE COLLEGE:

(Nor I rjsrcspoEibjrfty ofDerr noD & fr(lry 'o

$L,Dn ort),rtEs nor iPPeicd tori$o$med in Dya! dworknrg r fu rh,e)

r'- \.,,." Dr q V.c" G.oLr'\,d

r.0, Dare.f nrth&^ee...l

rir) cul.nrPiorolDFr i s.rcrt4co\' \ 'n ,r!,

rssp..icopy/r ^\gi:rdlvdd

rD/Aidhii cldN,,,,,r,.,...AMLBP |i,! laf r\ru..rL,v ..CJlrLrr o{

Norc t) wiihuui l,horo ID, Dedai.ion ronn ryi| be rejcded Jnd x,i nolr€aching faculiy. 2) Orisinal Ccrifi. es iE nrndarory ro.c.nific €r/Do nenrvcgnificdTr na ons, hustbe in Fnglish

DEcLARATIoN FoRM: 2018-.t9 - FACULTY

.. A'", -rour Protrq-nvcert,ticncopicsol|]1.s.rrpFor rbn.nortlcr p.e$rironirurcitri.hc!]

,,dj

Nitr re.r jfN-hnc n ti) R!N$,r'/ .o,h,(trit /r\(t F.o t,it"u.r,,a, r, ', * r " .. -

G)1\" 'or $ rlri

1.(drvi. 'ril"

d l1.r...y*i j,, \ii:\cl: Lc/pc/^ ,y orh- A.-*." r o6br4, . hi.r.

.td ,tr i.v -.tNrk Y9,,\o

l.(d)viii wh.rrrcf .pr.,rrulr rlr i..trto(t r Lin rrct uc/f.D.ssndion, Y.ry'lNo

l.(,r)ix /7 \vh.'ho yoo hiv. rrbrcd noDr c.rcrrrcr De(rrrit.o cse ys / vr'rf y6,

A/ 4, |.t1!,'l;

r.G) (b) Penunent Rsidolriat Aljdrass ot Enrptoyec :

1.(0 f.l"p,'.eT irmor Bd. , Lf*o,r hop ar \4c. | , s.o."t . . , ._ot tr rort Lnu$t rrd.tRcsiartt ccLte oL_ tutEhty.

Nahcof MCI Pegiotu Cenrrc \ih;; Da tc ,,/ //n.. .f bJ rndTmitjnAvas.tone/ Il ttninntx tuns dorc ,tcott.ge, giu. th. detaits ol t|; obsetuer

in MET

"s' :"'l-'.:i lt:'!:lll:'".fid / r," rti,\ Brr,1 n, ,ilc , ropru1c Bi, /aldnni'd/a(J(neo,s i proor orrcsidencc yerNo

r. (h) cotrractparri.trrars: fet(or|*), Ctllq6- Q{q3Am (_iihsrD-,r")

Drreorjoini'rsprescniiNrilubonr Ar[d6lar]to ar aa.qiq{dur R.[-.Fg:r1 (r)

1. (' Joini"s .epon at fl1e present Nrilu re dh.tE t _ yglNo

Note For rrc-Post r,6 qualrli.arron sdditionilRqhh?tion cerrili.ale pi(rutar b. tutrish.d aidsubjer beafter*onng outNhicheverisn iappljcable.

2.(a) Copyof Desree.eitifi.ires of MlJBsindPcdesreertri.h€d-YJ4No

2. (b) copy ol Resistation of MDBS an<l l,c dcsree arrrched , YJrNo

I (a) Deta'l.oI rhe ki.hng..pc tro.e h ldde

Noi* Turor/ RcsidentvorkinS in Anesthesiaerceience in the .espcdive depdmenb.onside. is senio'..6ident.

rnd Ridio-diaSnosis nusin a re.ognizedlperniried

MBSS

Gtrr I3\q! cql,"n! tqq6-

q00l{6I'ol&02

1.Mc

C43!t rolc"ET, cr\c,r 6q\td Q(l]3-

{oo6'lcua

[^€dlc"t

3{b). To he6|ed in by t\ Army f€bonnetonty:

Norer t Lve you b€€n cotujdered in any UClpC insp€.tionduringtd3ye.rc. lf y6.ple$e givederiits.

ar ant orher imtitution/hedjcar olese

Number ot R6eakh publjc.tions in Lr,l* Jounat6:

H* Finine p*,,r ^tiruron

I Bd wo4,n3 ,tEsnins / reh n8 /Tnnsirr;;rmdr!rion).

-aIt€r

I encros€d fron ihe pEvjous

5 (a) r^tedhhonatJoumalsl

s k) sbb/r6htohoNtJoumats:

6. (b)

My PAN c*.r N.. tu nNFRp 4016-i

M,A"dh".cdN. h 3ft{lqo3 N{")g

6. (c) Ihavedrareiftr.teinolumerbnom isco csei,lrtreNrcrrri,i,.iilfcarrsu !r:

2AAA^

6. (c ) (copy or my PAN & Forn 16 {rDs.eftIi.are) Ior liian.iat yerr 20r 61 7 arc aractEd)

DECL4RAIION

t.

3.

2.

L Dr."- *o,ki,s* flaar!'r.-r A.lf&i" rh"

I have not prescnred myself t. iry orherResiilenr ii drec('renii.ade i.l,eir for rlE

I a'n noi hav'nt privar Pracri.e

+_ Ir1..r"'h

Medi.al Colle8e / nntihrtior as a tiNth /purPosc of Mcr.$essnrni

anlwhPre oR I nn

hooF ot pfidre ire_ ro _.Funher j *ite rhar r D nor doi,rg ai, prnd.Pia.tie or no$vo*i'rg i'r iny othcr hospiral (tui'rg.otte8e hou6

Co,nfldE dehils NIlr regrn to ,eork experie(e has t€er p!.u(t(t & i.d,ir8 his 1{rn

r im norrforki,t i,1rry orrcr nrediclc.[e8c/dcnh].olle8e i,r rtre srare.rouGidc rr.srar,in anycapicity: Rcsurar/ conri.rnl/ alihN.-- lir rtjme/ pmtiim / Hdmn.l

It is deldod rhar each st kment and/or onrents of rhis dectaraiion and /or dmtrme.6,€rtifkd6 subniitrrl ndrS wiih th€ d<jaraiion fom, b, rhe und6sis,"j

"E ab$l,bli

rrue .ormr and aurhcnri.. In rhe ev€nt of any sblemenr nade in thjs dda6ho;sub6equently turniig out to be inortut or tahe the undereigned has undeGtood .nd

@kd rr i 8rcs 'ni$o' du4 r\c?bu

'end4.n8 rE I i":'8n

disrip'imry i fon {rndldtr '3

f'novat oI hi. hme ,;on, tr;r M..!

""" xlo+l {o+lr"* t'.rov,q96sJ

ENDONSEMENT

L This endorsment is rhe cerritcation rhir dre nndersigned has sitistied htn,€tI /hcRabout ihe corehss and ve.aci9, of each entcnr ot thh d{t ation and.ndo6s rhc iboveMboned dstaGtion rs rue and cou<1, I have verifj€d rhe crtt6..r.s / ito.unentsshmiE.d by-lheondiddte wnh rhp odctnit .edirior€vdoru menre * rubnj.red b), rhptc.chs bo rh.Imrirule and wnh rh.rcn(ern.d Inrti(ure.nd h,eetound rhen ro be orKr

2 I rko €nlirm tiit D. b not pra.hcinS or caiiying our

L

any orh€r acnvity dlri'rs m .3e Norkins hou6 i.e. rbn lifi,^b qpn4 sin@ he/she

In the aat of this ddaiition tumill8 out io be either imor<r or any parl ot thisd{hnrbn rubsequ€nrt} tunlng our ro b€ jncorcr or lake it h r"da$..j

";d a<epk.1

uur $p ude,uSncd nhllal, Leeqld v relpotu,bt" b€sde< rhF dtrd:nr h,n{r, hecetlro!any su.h

'iisdedi'rr'on or mi*hremerr

D.",06 [o"l{ol? counhBiSned wirh danp b), rhe

zPi'il($;;"T-!i'Ph*, tvtlvo€ee!

/

/

plrqot( o4(do l1

Counrediened Rirh Ji'r]Pp"". odo?ld?11;- .

9l

NqThe Oecl.ntion Form will not r,c r(epted rd rhe pc6on will nor be countPd rs tei'her ifrnvol rhe roov do(' n nr "e ro'' rlo'cd rr'ich.d s!r'ii'" '"i- - rr* be 'ou i.r F

' I r... |

' 'eo,:bir'ror froro rD Ptuor R's rurio'c.riti.r* / o"n*" -*ifi.t*/ r^N cird / shre Mcdi'rl coun'ir ID (ir issuadl m not

Diodu!e'l for verrkrion *'he 'i:. iri ,r." ".'r, "

, uq !ubmi' r ,('i'ed treJar io, ro,r 'r 'F ' ro'ri on\ lanv- l;cra;riion tom $b irted inin ord lormit rvirr not be a'cepted dtd hesilrnot bc'ounrc'r

8!M4B{9

ffiifr;F-tnn.un d* Emplove, sisned bv Dcaf /f'.rd,lo iP oLL" !

=rloiolDproof's!edbyGu.r Adhorho In$Pr / r^\C.,:d \ot' ll A' l ' d

CPd hed.op,6of pre\.' ripPoLr

,oG|wirka- F t' "/,r.anrc"ia / oo,r" nltutro,tler?f.ttiched as i prool oI

-.oT "n -;N '1- Jitt!{.1:.lls r,f-" . 1,

ii" I r!_: ll l rrs l-copyore potr' reLerr Ior roriLnr.h i3rPPurrners

',1. Lfl" n '. or"1. ' 'ir'ili- r,l"ionrleo' o"rf fo'

I.orrorIDq.,.iti. )ro . d., r''y.ir.

Y9, No

"y/ ^.,.j/ , ,

{9/ N'

ry*5

\!/ N'

t2. Ldhr Lrc L,r 1i', -'ed tr{lF . F lo I c. prr illlELCopy of uC F(o8iizcn !J eU,ne6 n -.... .

copyrfrc Rognid rcr.her e

Un r'/6'h,lro P.C As$n,L r)cdotorl\idharcard

'&h", si

NAME OF THE COLLEGEI

p*eolA$$snEd

l

u,, r.r r,1 Y.l| ' D o,r..,.a.\6 i'15:9.1 aoq\.

ll

' n

il:t'i;'l:[]"",i:r".:'*,,.r 1,"c.,,.r,,r,.i,"-.Pr$po!'.gtlrAN crd/rd( rDl^adhji criNL,,,,L,. L.l+55!tgt . r,,.",r 1,, Croi,tt CI

No'all, hi hou' rho o ra D-.t,. i d ,,,n \ |

:lii;::," ""

"':'', ;,,.: iii,,1,;ll ;1.;,Ji;,;;"1,,-,';'

Itrdtl

r ." "-", =Gagrc'l +c"[ s. l-N.l l!

l-. rl,Lr.nclo

I !{t, c,ilul ,, rl

ii. ,;; r-,.o'-,ll.r=', - ' , n"lo'n'.,

,..1,',"',. 'rq

i"i"'li:;iilg,.:" i("ur " .ir \c - Lc/'c ^s-\ndn

o,5 nr

i:1",il:1 il'"'1" "'" "-, .".o *' r,i-...,r -.,,,11" !s,/ rd Ji y-

irrlnFrrt!roir,11] l $ tmL||,

'.1 ..,,;.-

,.4*,,

P6enr R6idenHat Addre$ of employee I

1(e) O) Pemehr Rsidennat Addre$ otEnptolee r

1.(t Har e yd uderSee t reing h -Ade. Corrse Wor*shop. at M( | F"gj6dt CcnrF6 MEt or nt lorr.oue8? undtR'SoMtc.tue ob,.;cb)@!

' n, ff:".$ :::T:j:f,"j::,*:ll i;g;;o "u, ^",,'"" '",ephone

Bi,, / aadh, cdd /r. (h) conkdparhcutaBj r.t (offje), OAqq QQqlqoo (wid,srDo,rq

Irob,reNumb€r: qLllarn "la

I_--!'.

1. (D

r. c)

Darror)oinins pr6dr irotitution, nr lar I aolr| * no"i^ora Ro[

Nme orMe negioa,l -Grr;iG-'lr.ft&$ @ dane/rf ttdinirg @ dou in.olkec, 8i,. the d.t4its oJ h;obsn l

Date ,x,t prae of @

Jojnins report ar the pcent indftub aitmned - ty'lNo . .

Q6qt3dolo+/o

c"-* r'^9"^11 .*,..* |ab1\4 Gf.rall

asql 3 TcM.irout l.^edtr^! aq\.&+ I 5oo.tuqG,icrnl L

TcM t

-I(-l4cco\\- Qdo6 Qcq\ 3

Qoo4

2. (b) copyolRcsistntion or MsRs rnd Pc d'sree irirdrcd _lctdro

rG) tJorliorrhe trlL rUe l{( \e slldi '

N;-. r"u/ R6',r"d **l i' s i"cxperience in rhc resPctbve(dnsiler N senior i€sd€ni

in i ie.ognized/Pcrnrirlcd

collese I Unive6iY

co \€ X9

DM/NU;T

.' J\,.-tur Ca"Lf o' 'rr'' f'll'fr' ior_ " { | ' 'l 'r' t '

-r,r-' hiLter5lolnrotrr\htrl!!tr is not rPP 'iDrc

.':'Ji:,,";:" l. ::, i;i.;;-.iiiars ""a r" *',* -' r"';' e"'"

DGil-n -T.::1 ""i.i{,"_ll!!J'*=

Cn"raerol q\rti-'{!- I-

L t*6, j or\.@ 1Med\cat ]

[Tliii

Tobe6 ed in by E Armyfedonnet ontyl

Nok: Havetou beei .o,sjdered

duringlasr3yeare rIres,ar rly othcr i,Njturion/hcdi.ai ..le3e

5. Nnmb€r oI Reearch Putrtications

Before joining prsenr iGritution I

/rlansre4ins G€ri*ins order k €el@d rbm rhe peious

e (il lnreftrri.itrounmk:

5. G ) 5bh/rn,htuhonir jornralsl

MyPANc*dN. is ntr pPta +6.63q

My a.,rh"...d N.. k 1q53o{rJl3qq3

4A9!rt nk"ed

(cl I have drawn rohl eeotunarb lroq drn coJJeae in the curcnr rinancjal year as u ndei,

6. (c ) (copt or n,y pAN & rbm l6 tTDserhrkire) ro,rj,E rrrryerr20rerTar€rb.h€dl

OECLARATION

/.o' -S_A.M. ro a

-=l..";:^iiJ :::;i,J X::i;:,"1:'ili;,1i1."".;t,lrt,;:It,.,, ",. u.,or am not haviirs p,jva,e plicti.e

";r.,_,";"."',,.",.. '-

- - - - in o" tlv ol_ t I am practicing ar

ho.,, .r p,dch.e.,ts

i,l,ufs;;13 "* ** " *'"""'".,",.""'".;,; ".."" & nod,i,rs h.x,..,'.':;:il":i{li{,.i,it;,:::il11":l;.t:fl :{i: lij iff :i,iti:,:#i?ffi * *,"

Hf.5i*lg : ::;"tit' f,".;l,J;,fl)Ji T1fl.- on,nd /o, d(Jm"n6he ,o'e, md r,hen,ii.

^ ,h" ";;i; .;; *fl;,:;,,lTi:':1,i,,,,""f:j:l:J:

:".ftF. jl iji{"il{ri'}i:Fr':i;:1,:#,":,.,,,:*_ll j:"#:,-rffii"ill.ffi ilfjl:'*nffi ',*:i'-lI.:tm,"';*;lJl*; ;#:.;

**. oalo+ltrpr"*. Monoosel

ENT}ORSEMENT

i+j:T#:tr ii [r:il:i:"li:_Hrti:"';5.i;.1 HjT. j:xi(i"tr:ni"*rtritti,rf :t","rnTt#**l;**"r"rtrfl*xJ."fi

-ffS

3,

drrah'o, lb.equsd, runms ",, b L r;,..;;*i;,"L

l1r"o_e"trm d*Dr ni'q_].qcoh_bnotpn,icjnsdorryinsout

;:,::::;*:",,,:*-"*-orkinshou6ie fb4 €Frn b rT{4_

"r*h"/"h"In the €ymr or this dtrtaFtion tonrr3 otrt ro b€ cihe, i'rorcr or iny pad of ,h(

',.,,," ",*ii}; :iiiri ulii *"i1,;i,ffi "5"1,fl',*,y;:i::1,*;;:t':it". -y"*t *"a"a".n"" ",

.r,,,.i ".1",.

tlre d*larant hjm*ttlh6elf

Dak, oqlorll+ ..,n**'*"0 *6*;, n,"Drector/Dean/principar

",,i$ts-F-

Re<(r f.Lipo I si-e pj@ d lhe rn Fdk-;=G;; r,-G;trhobrD prcd i*Kd Lvcdiqud;;; F;t;;i; iNL:fd / vorerjD / qidh:rCrrd

fill,,l"J -''. " **';;;',,*;;*-** Y /Nocopr or pspo*

'r,ore.cra/ ercJr-rrlti 7rc-ilioni-Eil/ qr.lhir.nd / Dein 5itto'mer rr"r"."i".t e,r,, ;e,..r.r\9// No

c.py..r p ",p i , \"8, c";I ta;;;;ij,-it it-r;; B,/ Ai4nirrr d lhdrcdi\ r pro, rofpe rnire i rc,:ten(

lgM-P-r.r 'h" P-* id t"-cop,o,

"r p"a*"

" i,r("r-; LJBE;,.lEr.i;;cop e, or Re!6hir.n or M0 ,s;;,tEEr;;c.pJ .r .. p",,",,.. .".h r,..h t;ll;-;;;i?.-;;;;ErsrevjnS.nre rr.n ir! p,ej ionrLnnnd or

Formr!CDs.eddi.irdr.;g! !!41!r rjrr!!,r.r-', r ;;;;"N)lopy or ua ,mlnrzed r.i.

'erlefterf umr!,lFhd

c.pv.r I c '"..r, "*d ts".h;t;i;t;;;1 ;EAq\e , rr rlor '. is$lmo r

NEMARKS

I

si6ed bvihelcadrerl

- tltltl

alrq 0610+ll+

4t:-siemd bvlhs Hop: 's!&r 05lo?lla

lsf!

Ii:;j;jt#:j::litl:::i:,."":3j:t, l:;,,:;":l,il;:Jil,:i,L.,lii1:,,,.'..".,,ne_p.6on \it mr be orded rs: rc:drer ir rhe oria nJt c

$'x";l:ls;:l;j.li;l:,';^i :;l rff."'il;',il:i::,'81;:? ''.ji'i:' :,.1 ii.,i:iit,.l:; ;,ili t,'$ l:;,,",,;ir lI:::,.::' i".'t," *..;, i:, i::; ;liJ

3,