NAME OF THE COLLEGE:

I II III IV

Signature of Assessor

Date of Assessment

Accepted? (YESjNO/ABSENT)

Name of the Assessor

DECLARATION FORM: 2014 - 2015 - FACUL TV

l.(d) Submit Photo ID proof issued by Govt. Authorities:Photo ID submitted : ~Passport copy / PAN Card / Voter ID / Aadhar Card

Number .Ac.AQ.f.( ..l4.3.q ..R. Issued by

1.(a) Name .r:e11TTA ~ At( 4. .0 .I5v1. .1.(b) Date of Birth & Age .~.~.-:-.l..-:-:.I.q.(<?? , ~~ ..ljy .

1.(c) Recent Passport size photo of the EmployeeSigned by Dean / Principal of the college.

(Without Photo ID, Declaration form will be rejected and will not be considered as teachingfaculty)

1.(e) i.

1.(e)(i)a Certified copies of present appointment order at present institute attached.

Department: i! A ~Ol..-V\i _

College: s,;dC£QA cP~ t1~Ca} u l(.!2.JJ2.

City: \) (d~'\ fA LJB-~ ,~

Nature of appointment: Regular / Contractual.

1.(e)ii.

1.(e) iii.

l.(e)iv.

l.(e) v.

1.(f) Residential Address of employee:c; 3. (\,\ W\CQvu:::t~ >r;cY t2--cPd\J\j~~o...l J.~<=&. A~-\-------------

1.(g) Have you undergone Training in "Basic Course Workshop" at MCr Regional Centrein MET or in your college under Regional Centre observership?

Yes DIf yes, give details.

Name of MCl Regional Centre where Date and place of trainingTraining was done/ If training was done incollege, give the details of the observerfrom RC

1.(h) Copy of Passport IV oter Card / Electricity Bill /felephone Bill / Aadhar Card attached as aproof of residence.

1.(i) Contact Particulars: Tel (Office): C 52 C: (. - 1- q C, G 30 C . ~'x (- 2 , t (with STD code)

Tel (Residence):-tr-+----..------------ (with STD code)

E-mail address: (1)' . \i,-, ,(~ Lh~?> d*,~le' c "\'\.S~i I • ((' •• 1 •

Mobile Number: __ 9L-9...L·' ....I..J--=7 ....'----L-'I--"'~__'('_- --=S'---"-S~ _

1. G) Date of joining present institution: <; .. t 7 - 7...C/ (, A· /"J as __ "-,--j--,l~J_' -.=....0_.y_.. _

1. G)a Joining report at the present institute attached.

2. Qualifications:

Registration Name of the StateQualification College University Year No. ofUG & Medical CouncilPG with date.--

11- -,rfL, y,>( 8,(rr, "clC" l.( c'l lj.",JV

MBBS ~'-(LQ:(:(c< ~y,:c,"- :.Ft "tV\ \/\..c ...•..... I(/,~0 J/<:'- 30

(c,.((\'l'~ \

Cc'I!''')'''! 1"Vt2--'1 -(1- 1'0 J

MD/MS

( )

DM/M.Ch.( )

Note: For PG-Post PG qualification additional Registration certificate particulars be furnished andsubject be indicated within brackets after scoring out whichever is not applicable .

./Copy of Degree certificates of MBBS and PG degree attached...../'Copy of Registration of MBBS and PG degree attached.

2. (a)

2. (b)

2

3 (a). Details of the previous appointments/teaching experience rJC \- o..P0'C,6. l..-cr '

Designation Department Name of From To TotalInstitution DD/MM/YY DD/MM/YY Experience

in years &months

Tutor/DemonstratorRegistrar/Senior Resident/Resident

AssistantProfessor

AssociateProfessor

Professor

Note:- Registrar/Senior Residents working in Anesthesia and Radio-diagnosis must have 3 yearsteaching experience in the respective departments in a recognized/permitted medicalinstitute as a Resident.

3(b). To be filled in by Ex Army Personnel only: Ni' r Ct~'~ L ~ C:.'1l-U'

S.No. Place of Posting DesignationPeriod

From To

1.

2.

3.

4.

5.

3

r Z

4 .(a) Before joining present institution I was working at 2 h c... ( "Ji 1lu.vVD<\Cu ...V-\ . asCj\)\ \ Ag::;\' SLVI..S<o\."-! . and relieved on·) ....Q7- Le)! '> 1"' rV' afterresigning / retimtg (Relieving order is enclosed from the previous institution).

5. (a) International Journals: _

5. (b) National Journals: _

5. (c) State/Other Journals: _

4 .(b) I am not working~ny other medical college/ dental college in the State or outside the Statein any capacity Regular / Contractual.

5. Number of Research publications in Journals during the last 3 (Three) academic years:

6. (a) My PAN Card No. is Ac.q P N Ib"(£1 P..

6. (b) I have drawn total emoluments from this college in the current financial year as under:-

Amount Received 14 TDS }LtJuly Jt 2--- 1 1ID I -August J..r 1- I 7JD r-September L~ Ill) /-October it 2.....7 J7) 1--November j\J L.f .; / "36 ~ /--

December Ne; -:;6 (, J - {L{ l j {)Oo/-

January L C '( 10 .~ J r: J.-I 1 I [lc)O/ -

February N\ ·z..£ 3, [>: (L,1· HJ ,O()/-March ,J-J ,- -Z h ~ /-April h \- (, 6 2./-May rt1 H <, ~6], /-

June ILJ If 7 I i 64- / -'J.-.O I L

6. (c) (Copy of my PAN & Form 16 (TDS certificate) for financial year ;"~(~ are attached)

4

DECLARATION

1. I, Dr. 0{, PLo! L A(e>, (4 C' \

Department of A '-'-Af2 ""\'-1College and do hereby give an undertaking that I am a full time teacher in

AV\ "1[C"-<''--lr-----------'' working from (1 A.M. to tr P.M. daily

at this Institute.

am working as _~l_·_L.{_·\~.()_\_/_. in the

at §,'d', J cI.:\c~"L~,-C'~ Medical

2. I have not presented myself to any other Institution as a faculty in the current academic yearfor the purpose of MCI assessment.

3. am not having private practice anywhere OR am practicing at

___________________ inthe city of andmy

hours of practice are to _

4. Complete details with regard to work experience has been provided & nothing has beenconcealed by me.

lt is declared that each statement and/ or contents of this declaration and / or documents,certificates submitted along with the declaration form, by the undersigned are absolutelytrue, correct and authentic. In the event of any statement made in this declarationsubsequently turning out to be incorrect or false the undersigned has understood andaccepted that such misdeclaration in respect to any content of this declaration shall also betreated as a gross misconduct thereby rendering the undersigned liable for necessarydisciplinary action (including removal of his name from Indian Medical Registe~).

A~T--)SIGNATURE OF THE EMPLOYEE

5.

Date: '7-11 - '2 Cl I '3

ENDORSEMENT

1. This endorsement is the certification that the undersigned has satisfied himself /herselfabout the correctness and veracity of each content of this declaration and endorses the abovementioned declaration as true and correct. I have verified the certificates / documentssubmitted by the candidate with the original certificates/documents as submitted by theteacher to the Institute and with the concerned Institute and have found them to becorrect and authentic.

2. I also confirm that Dr. _--'N--'----" ~'----.-'-'(..=-'"\9J-""'.L-I""'2",,C=-) _0_''-.1 is not practicing or carrying out

any other activity during college working hours i.e. from q Ar( to Lt E 0'. since he/she

has joined the Institute.

3. In the event of this declaration turning out to be either incorrect or any part of thisdeclaration subsequently turning out to be incorrect or false it is understood and acceptedthat the undersigned shall also be equally responsible besides the declarant himself/herselffor any such misdeclaration or misstatement.

Date:Place:

,-II-Let;,

\':\J'e,~ ";..£1~ •

~-~~.~~\.~Signed by the HOD g {(t ( (.3 .counte"ign~e

Director/ Dean/ PrincipalPRINCIPf.\l

S\oDH~RTH~MEDICAL~OllEGEGOVT. Of A. fT.

VUAYA,'NADA-520 DOS.

" ,qG,.~";a.r(:/{:., ·-'.~ ,-J

,-. ~~

Sidl..\'n ,',\I .1) [.,

r

REMARKS

S.No Documents Submitted.,./1. Recent Passport size photo of the Employee, Signed by Dean / v'Yes / No

Principal of the college.~. Photo ID proof issued by Govt. Authorities: Passport / PAN __ Yes

/ NoCard / Voter ID / Aadhar Card

.........3. Certified copies of present appointment order at present ...,....-yes/ NoInstitute.

./il. Copy of Passport /Voter Card / Electricity Bill / Telephone Bill ..--?Yes / No/ Aadhar Card attached as a proof of residence.

---5. Joining report at the present institute. ..........Yes/ No.../(,. Copies of Degree certificates of MBBS and PG degree. '-"'"""""Yes/ No-"7. Copies of Registration of MBBS and PG degree. .../Yes / No

8. Copy of experience certificate for all teaching appointments Yes / Noheld before joining present institute .

./'"9. Relieving order from the previous institution. -/' Yes / No/10. PAN Card """'--Yes/ Nov'11. Form 16 (TDS certificate) for the last financial year. ~Yes / No

12. Letter head (in case of teachers who are practicing) Yes / No ....---

Signed by the Teacher:Date:

Ue~,d:1 j •••.; •.

":;over~ :;:r;~··: ',

,:,.• sl\

Countersi , ea Princi al: 6i(Jei ;~' 'Gc!j

)';JF f P.,: ,;\1))..

NOTE:

1. The Declaration Form will not be accepted and the person will not be counted as teacher ifany of the above documents are not enclosed / attached with the Declaration Form.

2. The person will not be counted as a teacher if the original of Photo ID proof, RegistrationCertificates / Degree certificates / PAN Card / State Medical Council ID (if issued) are notproduced for verification at the time of assessment.

3. All the teachers must submit the revised declaration form in this format only. (Anydeclaration form submitted in an old format will not be accepted and he will not be countedas a teacher.)

6