Rajiv Gandhi University of Health Sciences, Karnataka

4th ‘T’ Block, Jayanagar, Bangalore – 560 041

Name of the College : _______________________________________________________ Date of Inspection : _________________________________ DECLARATION FORM – 2012 - 2013
1.(a) Dr./Mr./Mrs./ Name……………………………………………………………. 1.(b) Date of Birth & Age …………………………….……………………………….. 1.(c) Recent Passport size photo of the Employee Signed 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 Number ……………………… Issued by …………………………… Photograph Photograph

Without Photo ID, Declaration form will be rejected and will not be considered as teaching faculty.
1.(e) i. Present Designation:________________________________________________________ 1.(e) ii. Department________________________________________________________________ 1.(e) iii. College: ___________________________________________________________________ 1.(e) iv. City: ______________________________________________________________________ 1.(e) v. Nature of appointment: Permanent / Temporary / Adhoc / Honorary / Part-time

1.(e) vi. Whether belongs to: SC / ST / OBC / Ex-service / Others. 1.(f ) Residential Address of employee : ______________________________________________________________ ________________________________________________________________ _________________________________________________________________ 1.(g ) Copy of Passport /Voter Card / Ration Card / Electricity Bill / Driving License Attached as a proof of residence. 1.(h ) Phone & Fax Number With Code: Office: Residence: _________________________________ _________________________________

E-mail address: _________________________________ Mobile Number : _________________________________ 1

4 .(c ) State/Other Journals: 6.(a ) Before joining present institution I was working at ________________________________ as _____________________________________ and relieved on ______________________ after resigning / retiring (Relieving order is enclosed from the previous institution). 2. Year Registration No. 5 . 3. Qualifications : Qualification Under Graduate Degree : College & Univ. Number of Research Projects on hand: 2 ___________________________ ___________________________ ___________________________ ___________________________ . Details of the previous appointments/teaching experience: Position Tutor/Demonstrator Registrar/Sr.Resident Assistant Professor Associate Professor Professor Name of Institution From DD/MM/YY To DD/MM/YY Total Experience in years & months 4 . of UG & PG with date Name of the State Council Post Graduate Degree : Additional Qualification: Note: For PG-Post PG qualification additional Registration certificate particulars be furnished and subject be furnished within brackets after scoring out whichever is not applicable. Number of Research publications in Journals during the last 3 (Three) academic years : 5 . 2.(b ) National Journals: 5 .1.(a ) International Journals: 5 .(b ) I am not working in any other college in the State or outside the State in any capacity full-time / part-time.(b ) Copies of Registration of UG and PG degree to be attached.(i ) Date of joining present institution : ________________________ as ______________________ 2.(a ) Copies of Degree certificates of UG and PG degree to be attached.

2006 August. I have verified the certificates/ documents submitted by the candidate with the original certificates/ documents as submitted by the teacher to the institute and with the concerned institute and have found them to be correct and authentic.(a ) I am having PAN Card and my PAN is ____________________/ I am not having PAN Card. certificates submitted alongwith the declaration form. 7 . I have not worked at any other college/institution or presented myself at any inspection from October 2007 onwards till date. 2006 January. 2007 TDS 7 . Date: Place: Signature of the Employee: Endorsement This endorsement is the certification that the undersigned has satisfied himself /herself about the correctness and veracity of each content of this declaration and endorses the abovementioned declaration as true and correct. It is declared that each statement and/or contents of this declaration and /or documents.(b ) I have drawn total emoluments from this college as under:- Amount Received July. 2006 October. 2. 2007 May. 2006 November. 2007 February. 2007 April. 2007 June. by the undersigned are absolutely true. correct and authentic.(c ) (Copy of my PAN & Form 16 (TDS certificate) for financial year 2005-2006 are attached) Declaration 1. In the event of this declaration turning out to be either incorrect or any part of this declaration subsequently turning out to be incorrect or false it is understood and accepted that the undersigned shall also be equally responsible besides the declarant himself/herself for any such misdeclaration or misstatement. 2007 March. 2006 September. In the event of any statement made in this declaration subsequently turning out to be incorrect or false the undersigned has understood and accepted that such misdeclaration in respect to any content of this declaration shall also be treated as a gross misconduct thereby rendering the undersigned liable for necessary disciplinary action.7 . 2006 December. Date: Place: Countersigned by the Director/Dean/Principal 3 .

(a) 7. Copy of experience certificate for all teaching appointments held before joining present institute. Copies of Registration of UG and PG degree.(c) 1.Sl. Relieving order from the previous institution.(a) 2.(d) 1. PAN Card Form 16 (TDS certificate) for financial year 2005-2006 Submitted Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No Signed by the Teacher : Date : Countersigned by Dean / Principal Date : Signed by the Inspector : Date : NOTE : 1. The person will not be counted as a teachers if the original of Photo ID proof. Photo ID proof issued by Govt.No 1. All the teachers must submit the revised declaration form in this format only.(a) 7. 3.(g) 2. The Declaration Form will not be accepted and the person will not be counted as teacher if any of the above documents are not enclosed / attached with the Declaration Form. Signed by Dean / Principal of the college. Authorities : Passport / Driving Licence / PAN Card / Voter ID Copy of Passport /Voter Card / Ration Card / Electricity Bill / Driving License Attached as a proof of residence. (Any declaration form submitted in an old format will not be accepted and he will not be counted as a teacher.(b) 3. 2.) 4 . Copies of Degree certificates of UG and PG degree. Registration Certificates / Degree certificates / PAN Card (if issued) are not produced for verification at the time of inspection.(c) Documents Recent Passport size photo of the Employee. 4.

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