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Medical Council of India Declaration Form 2010-2011- Resident

Medical Council of India Declaration Form 2010-2011- Resident

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Published by drtpk
Here find the latest Declaration form for Residents prescribed by the Medical Council of India for the year 2010-2011.
Here find the latest Declaration form for Residents prescribed by the Medical Council of India for the year 2010-2011.

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Published by: drtpk on Nov 06, 2009
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11/12/2012

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E:\MUKESH- 15.04.2009 ONWARDS\BLANK FORMAT\FINAL -DECLARATION FORM 2010-2011 - RESIDENT.doc
NAME OF THE COLLEGE 
:_____________________________________________________IIIIIIIVDate of InspectionAccepted?(YES/NO/ABSENT)Name of the InspectorSignature of Inspector
DECLARATION FORM : 2010 – 2011 -
RESIDENT
 
1.(a) Dr. Name…..……………………………………………………………….1.(b) Date of Birth & Age ………………………………………………………1.(c) Recent Passport size photo of the EmployeeSigned by Dean / Principal of the college.1.(d) Submit Photo ID proof issued by Govt. Authorities : 
Photo ID submitted :Passport copy / Driving Licence / PAN Card / Voter ID/MCI Smart ID Card/State Medical Council ID. 
Number ……………………….……………… Issued by ..………………………………..………
(Without Photo ID, Declaration form will be rejected and will not beconsidered as teaching faculty)
1.(e) i.PresentDesignation:_________________________________________________________ 1.(e)(i)a Certified copies of present appointment order at present instituteattached.1.(e)ii. Department: _______________________________________________________________ 1.(e) iii. College: ___________________________________________________________________ 1.(e)iv.City:_______________________________________________________________________ 1.(e) v. Nature of appointment: Full-time/ Part-time1.(e) vi.Whether belongs to : SC / ST / OBC /Others.1.(f ) Residential Address of employee : ___________________________________________________________________________   ___________________________________________________________________________ 
 
PHOTOGRAPH TOBECOUTERSIGNEDBY THEDEAN/PRINCIPAL
 
 ___________________________________________________________________________ 
2
 
1.(g )
Copy of Passport /Voter Card / Ration Card / Electricity Bill / DrivingLicense Attached as a proof of residence.
1.(h )Contact Particulars: Tel (Office):____________________________________(with STDcode) Tel (Residence): ________________________________ (with STDcode)E-mail address: _______________________________________________ Mobile Number: ______________________________________________ 1.(i )Date of joining present institution : _______________________ as ________________________ 1.(i)a Joining report at the present institute attached.2. Qualifications :
QualificationCollegeUniversityYearRegistration No. of UG & PGwith dateName of theState MedicalCouncil
MBBSMD/MS()DM/M.Ch.()
Note:
For PG-Post PG qualification additional Registration certificate particularsbe furnished and subject be furnished within brackets after scoring outwhichever is not applicable.2.(a )
Copies of Degree certificates of MBBS and PG degree attached.
2.(b )
Copies of Registration of MBBS and PG degree attached.
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