Shree Saurashtra Patel Sewa Samaj Sanchalit

SMT. N. M. PADALIA PHARMACY COLLEGE

Approved by AICTE and PCI, Affiliated to Gujarat Technological University
Sarkhej - Changodar Road, Near Sanathal Circle, Navapura, Ahmedabad 382 210
Phone- +919099063162 Email: snmppc@gmail.com Website: www.snmppc.org.in
REGISTRATION FORM
REFRESHER COURSE FOR REGISTERED PHARMACISTS
Sponsored by:
GUJARAT STATE PHARMACY COUNCIL,
Block No. 4/A, 3rd Floor,, Old Nursing College building,
Opp. Cancer Hospital, Gate No 6, Civil Hospital Campus, Asarva, Ahmedabad 380016
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Name (As per GSPC certificate) : OZA PARTHKUMAR NAVNEETRAY
_____________________________________________________
23/08/1990
Date of Birth _________ 28
________________________ Age:_________________________________

B.Pharmacy
Highest qualification:__________________________ Pharmacist
Designation: ________________________
G56814
GSPC Registration no:________________________ 31/12/2015
Date of Last Renewal: ________________

Astha hospital
Name and Address of Present Institute / Organization: _______________________________
Near limboo shoap,veraval road,keshod.
_____________________________________________________________________________________
_____________________________________________________________________________________
Address of Communication: #277,”shreeji” shreenagar society
_________________________________________________________
Near sanjay school,keshod -362220
_____________________________________________________________________________________
_____________________________________________________________________________________
9426957872
Contact No: (M): _________________________________ (O): ______________________________

parthoza23@gmail.com
E-mail:_____________________________________________________________________________

Details of Registration fee Rs. 300/-

Mode of Payment: NEFT / Cash /DD
DD No: ________________________________ Date: ______________________________________
For NEFT; Transaction No: ____________________________Date:
Net banking-UA0147130358 ________________________
11/3/2019

Bank Name: Bank of India, Account No: 200410210000003, IFSC code: BKID0002004

Date: 11/3/2019 Signature of Applicant:

Enclosure:
1) Self attested photocopy of “Pharmacy Registration Certificate”
2) Self attested photocopy of “Receipt of Last Renewal”
3)DD of Rs. 300/- in favour of Smt. N. M. Padalia Pharmacy College, payable at Ahmedabad