NAME OF THE COLLEGE: ,ga>+-6L,AL

Nore, 1l ['nhour phoro ID De.lmtion foh will be reFded and wiritpa.hinA lr.ulty. 2) origin ceniri.rtcs rc nmdaiorycsri{i.*evDocunedi/cdtiried rrnnsraiions, mun bc in Ensiish

l.(l) .

N.iura.f .\,1{ii'nD.rr ti)

(')

tfridh. rDoLni .tr,J r(DrJ r L.brr^u.. is..rn,rlh+hd app.i)<d , fd rleptrJ ii', Lan Mcl - uc/Pc

'' .'. r'"...- Ytt,, iz"n,ar P.reYaSCdr 9-oy l- . ttt<i{; a Cal t9p4

DECLA rroN FoRm : 2ols-2o - FACULTY

Pi*po*.dpr/ P^N c d/vorcr lDlAr,lhircaitl

lr".u"Af S.l2 c o9lo5-ft L,*-u,r

. ",*., ^, s,,."," D"+o:s.< rl.-4

"f., d copn d p,e\e n"noo ih4r., ie, r oaer'nr..r L .i. Td

..r1",. tm c , " rvro 4 r ^l C- lle* [<or].;L'tJ",c!, I<or-l^ . L.oAs- - !

r(:trrr / c!r{tu , non* @--+^Lq-"'r',li r^. rrrr r-., rr..-"* Tn "ii.' w,,r-i,, r"' * r-. "-,

,,q^ o.l* a*-- -, rlld,lI"r,,.rCrlkp. &o>1frFoJa

Nrcr - Lrc/rr \$r+trr, Li dL eme

_-9 -! ko)-h" l{Aaifo

rhc i r,6itre it ^dllr$!rcr

lG) (hl Pdmanlnr Rdidenhct ^d,lrt$

orr,npto)ee:

.K-'l"Lad" 6)SL<<os{L q/.=di

r(0 '1:.::j.,"",3", 'r"i, rri,n 3d. \ r.! ho,r,1.r ,, v, I p"8'ondt ( p.u"tn \r I ot,r uor.o g..,,,d.t Rsiontc trob,.tufl.hi:

v,L *f4

Narneor MO n.giomtCente wtwe Datr a,/r'ra?.f hnn iiIr^)niA\|^s done / tl htntngunsdsrc r.o .s, s^t rcd.iaihol kc ob{ru4

' o :;ii:j :fi:':Ai;;':l1J

"9";;o

" ^"',''" '"rePhono Biri / Aadha' card /

r (h) conr,ru'adicura,. rer(oni..),o&q5 .iZq 3o4t> (,"lhslo_de)

..t.1. ,,,....)oqq6,A3 f5:6+7 ".,r " n ..,rr ....,r, "".r . *. c Aolt a .n qNlv.tg tg+a.bgq<o. r.o

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r'(r)

L (i)

ni"o { iBo'c"n,',n'ul.,: +L4}"Lt ". ?="&so.,l,

'n'B rer,

'. | | rc pre\t i' ji,,,""",.',.,'- ka.t *,,

4_ r- -T l lResi.iid:on

QuJ if. rio. (orreee urtr{'ih ] ld'

""ojj'n

ffi.l"d ['fixPt (4"'')eEa '.Lm'-

l"f , ""iffi5j"t*sr, ,r,, \J?tg ",.^.I:{:'6\W"Hfr ril"'#ff '*r_:t

:l%t t u"e) r'-5 l*"r^ ?PffiT,

1ffi;;-

Note For PG-Po{.Pc qualilicati.tr addirioialR+istation ci rcare prticuhr' be lu'rished an'l

sur,jed bealre' sonng.ur whichd.i is nor appli.able

2 (,r ) copy or Desr.e.eniticarcs or MsBs rnd Pc degrce atta'hrl - tres^o

2 (hl CopyornsgGkiiionorMBSSandPCdegrccrta.hed-iet4{'

'r'|'e '!i i |'r"

ep";*

-N"...'r

Il'

-rdar-DD,ar{llrna lxpcrien.e

lri{tlurroiogs,, ,

> Ll lot2tflo3 At LF'

u16+orItl.{.J

r 39f b..lt 6l,rl B tY!18

/ ,., i,{f, r ((

1 1"Ltft, \a) tu^ -

"nt. ( oe!{

fuuF sa r'lql,)ieB:t. u?Kn€sdi....; I o 6.ui isL-, rlglo:l9-'t'vTNnssdi....; I o 6.u.r'i<il-^ rlglo:

_ l..nD_l{i rd4r, _o,^,r *.. , "Jot'"ob $,PaPr' <rrt'*W,+.i& ''l+l'.

s1?zlqsq lq'z

{ lrl rt

ro he fitcd in b) E\ ArmJ r(60nnetoit)i

[" ",.

Nor.:ri.'rrv.ubrn(ft .rcdduri|8ta*rylrir l rrs,

ir ril i rhern{hrnniir,t!at!o rgr

.d;l+st.]; "- "" " " ], ", r:i".ftg,f t fSFI":iil:,i:",,. "",. 1.f,' lns,Rerievirs o,de, a endd-d.,.om rfe,,e!,ou,

Nu mb., ot RcQr.h Nbticario's i,r Lrn \ ldtrMh:

r t.,t r,,,.".,ri."rt,*,n,t,, 75 t,) N.ri.-"tl,!,-t,, lt5 (. I Sn'c/

'shLuro,, rlt un l\

6. (.r Ml PAN c-.r N.. i" A," S pt_6? o , 9-o rL,r nr-,n-rr", -,.r N" i. Fg-oe-elq7 *4L6.(c) Ih.v(dmsntobtemolufienbnoDrdristolcg.inrtrecuiienttin,n.i yearasund.r:

L[:4:i*3I_ L_

,,,', UK eloJb<lw.a "'..ki"s6 pqeg{4gorY -n"

,).r,",,,,,,1 ,' og+ ", -krn!'1 v.n.al

' ttr- . \ 't l, '.1,'-, ^ ' ..-.',t .,

' m h. \e.

'FkNc-'f rA.e/hlrs0- CallgP*.,"*- 9"" E 'vddn

I l'.i. iir pr€pni.d D,yscLi to in) .ther

| ,tr, rn |,,tri,,[

Modicil Coll.gc / hslirlti.tr n a laolil /ptr,posf or Mcl asesDc I

: tr 'lc!'J

i

houa'or r)odL.,.nr ' ll!trrhc' I nit dn( | am

rrrdiror fot trorl ,g ,,!,ydLlI1hos iildu'i"3..llegehoure

Cort).11 Jehih rlrh '$ar b,wr crpoicmc ha! b1en l)rov Li & norhi'rg hd bQn

!,nrri\orIng]n.r,]rdro,N(hrln)$./dcni,ltolkg.i,,theshLro]oLtsJcthcShti,' d '!.ipNtv: R$uL.r / cnnti.!ri/ \Llh.. -- F!llrid'P/ Paittirne / I lononrr

lr is (lcdito.l thit ei.h $altmenr and/or.oit.nrs ol rhis d{larahol rxl /or (lo(uoenb,..rhticai.s \ubmined al,{r !vi(h th. dedirition lorm, by the undc'igned ie absoluiely!ue,.oii.d and lrhpnU. 1,, rhr cvpnt of y s:.tentit o.de in rhis de.lantion!trI\{ rn} turi'rg our b b. LD..ru.r o' ftlse tl,e unden\r,ead+trJ rhit srch mi\J.d{rrt(F i, rgsp.ft tu i,ry..nFnrol ihh d\.. imiion shal ilnib.

J \ilni,., 1 rd o ' I'n.luLli,r n n,o\iloi In rDr'rnD rn!]Lr Nr(al,(ill('l'nc)

SICN^TURI OI THE EMPLOYE[D,tr_ osl06\&o{Ei

^v-rl\L/t N)ed'^Lep@u4tl4F<a>-trw! a& "

ENDORSEMENT

This crdo^ed'ent is thc.cnifnauon rhar the undc6igied has saiisfidd himself /hecelrdh)dtihccorNirL$adilveracityorerhconcitofdrisdedaitj.nriden o6os the above

nrnho&d .{slararbr is tu. ir one.t I have veiried the.ciificat€s/ docunenssubniri€d by rhe.andid'te wirh ih.originJ ceniri.d€tdo.unenrs as submited bv the

hr.her io rh. ln$nuie and with th. .onccrned In*irute d h

r "r* -,,r-. ihd D,. V K Ck JLr.d!av\,\4 n rcr p,achc,ns o..atryms ou,

,.1r",r'.r,.,.dJrBdhr" r,,s "-,.,. r. " B-.On" qZ^Q.."'"'"hi5 j(D'dd rhe Inshiutc.

3 11 rlrg evcnr of ths de.la:?rion runli'r8 out io be eithcr incored or anv Ptut of thirLreLirrhoi subdequenrly iurning oui ro bc in.oiied or fals it G trndodood dnd a(€pted

rhdt rhe r tNiSned shrll also b..qurlly rcspons ible beides dre dc.lara nt hi mself/ heEelf

foratry s'ch misdeclaRtion ormishtemenr'

t,,v-\-/cotrntc'sign..li! th {imp try

r)ncdf/Dd.' VPri'sri

-Iiim1'jj-jl{:'

' \'' -2@-t," eblobl\oLr sir'.i t. r'rr!'r'-' lzr.tc-i ' fq€ru (4/ ^Cdlag l<">\i!o& .

t!!!!4!r:

!l!Rd!'rt Pa$pon size phob of ihe EmPloyee, Signed by Dean /Pri,tripal ofihercllcge

y/*'l-j'',,1,.fl1'l"lul#ll,n''n"

*"-'*"..** It'l t"

-"11I".l;F.*,' r*, ,pp *..r ord{ i, p€ef r Uzl u'

r"r. -, r'^'p..1 /vtlR,,i ; ik! r i\ B rr / rrrrph.'E 11, I

, ^ hxs,,J/ t\.,rt ,rro'mu Lr{.r ,m r4i 3 ' I s ,r

I (") a.r,r,,r I,.6.p,i7tdd cr,l / rL..bietv Biil/ liLephoneBill

/ Ardharcard attachcd is a pro.r .ft94!!!t!l9g!9!!!:lohitrs rcpo{r thr Plesed m$nry

-c@'"lrusq,ir,'"tNtgss-'n:.r.g,-

CL neu, Feqi5nihun I MEn5 l l!.1!g'\'c.pt or erpcricn.c e{ilicat forillrea.hrng appoi'tmcnbhclLl bdorcjoi'rins prcs.nr i'$tituItelievn,a onlej ton thc prcvious in$Lt49ll

f, oLErdiritl h. 'he

li$lr"rnlr.nr.*-.r", t*-t t**.r.".1.,. "t".* o,^t.q)

-aduc

.-a' J,-...' r ( r.r!!!!r!!

copt olr.c. tu.ogrized ieacher leftf rroh rfrjlii.edunivLBity.0or P.c

^sscsDrenr)

sk*d b",h"r"".hts&r---o',-oaFofsptr

codniereiene,r liih shnr bv pcr6 / I'rin.irs

"€&e-(ao lA-

,l,o'PPrNcl'ii.EGe

lt"'-,,' """'!lx!s-d-glt!lis!-b{lE ar!!!

P!q-

\41!The Dclaration Forn will not be r(epted and the pe*onflill nor be counted as reachei iranyof rheabove do.um€na are not€ndosed/adach€dwirhthe Dedaration Form,The peKon will not be counted as i teacher ir the original of Phoio ID proof. RcEiskaiioncedirkates / Degreu cedifi.d.s / PAN crd / si e Medicd coun.il ID (if issled)aie notpdducdd for vrdtic ion d thetjAil rhc,rca.hcr mlst submii rh. revised dehrrtion roin in ihis fornur onry. (Anydldrntion {om submiric,l in rn old fornai willnot be rsepted and hc wili not be counted

NAME OF THE COLLEGE:

l{lol::ar

1."4M!l]rYlt1

DEGLARATIoN FORM : 20l9-2O - FACUl ry

c..y^- ss loEr {E

Pq"cessoe

OBs rE tc!: &, G!4.\lAE<4!e!'7corLr(. t<.! . .-T_-ME!"La-FI Ca_tJ-_Ee.E :ylltNASsERr

1t,r)!i

R-h-c:r (]-LLc-c.rli"-r'- S<..1 , 'l\Lr'o

r

lNdcrris'e\pon!ibjrryof D..rn, ()D&tun'l!, 1o n'bnri oirrhr

r.j \-, oC. SO.N.BI{AGIA J? l<lVIALnhl

,31,,1'a-tl i 65.16r (o subnr it Phi)b ll) Foor is].J $,co\r

^u uid\

Ihoro ID n,bmi(.d: /Iisspoi.opyl r,^\ r:rrd/ v** lr)/

^rJ.hdin.' .P A,rv p,- usdorv | ,.. ' Ci ,{

J ^*,-r- , t..36 tuLi<* 4- G.6

Ndc r) wi'hoi ph"r, rD, bodr.!i,,n r,"- *i]| t.. reicd.d md lillreidriry fJ.uly. 4 oriSirilcuriri.rr.rDo.umcnrVa.nified tnndJr on!, mun hc in rrglish

| (1)

..'. r-Arr,_ur 61SSozn,u." ; ay,^r**, 1"1 oqlK /.-t,.,n*r rur.,. Rg{s!"

p1n'iirrr" 1r."r ti."/u.,",. - -C1.)1!l[orr\ rrr)nr fnvdc fridk"].d- a]t Fs\-_!ar f6u-f A'' I ''.1o nr l< .r\.a-:]-- }1cl:cJ c,tG.ra l&-3:ics \,, . ,t. /','\[]'i-,<,N

Wh.tltr v.tr hiv. r.in.(l

,, f-l r t . \lr | - | !/l{- {s,*tr, 'r o' qr.,

rtur cor.nmu, n,pdi.rr .,rc,:,. v- r iil, r."..

'g]dpH|riJ6lPAfIi.u[

(a) r,reser r Rc$,rpdhir Ad(rruss or .Dr d!,yf.5{. <.il Err4cr./ A -Fi la,o ul6LaGi-A r- ,. G"U"- E^€Lv- AFo."lEe4

C.t"\"eij"^x, .At r.

I (d (b) Pumancdlisnieriial Addr.ssorEmploycc:

@L3l4 / _6

vo,\o Aere ':611 ao-4 : l<A sNiaraun

N.Z

.i;;.;iii- r\ii*,r c., "h; --t-"t d;?,,*".r i.;s

'rnilins w.s dono//rdr,;,J.c!r l.,1 rr' .al 4a sil'r Ih. &tnits ol th. oh! fl.|

-r*.Lcl ).r c... -B-l-Et"r-

un(t.rgoirl innr8 i'r "rt'str coure w.rksh.t" il i\1clnr ,t ltow eoll.$ u (t t tio"rl Cr,t,1 obs.nt^ht'1

Dar, or,oinjrs p,esenr i,,stihihn IZJ.r.213c "" Pbal.ls."(Joinins r.pon ri the ptusdr indii"

" ...r..r - rf"l r'u

ri0

r (s)

r.(r)

r(t

.\

copy or Psron /voter ( rd/rdachPd rs a Pd.fof (5idorr

Elca:i.iiy uillAandlinc r.rcfhon. Ri|/A hr.xd/!.:vND LFG 6(<- dtt":\Ed

T$c

Nlnns G\lelfHq+&

-*ll;';".t-*y,,fS*

2 (a) copy ot Dasr.. (riri.ai$ olvBBsridl(;d'sPe'tradred-lJtlro

2(b) copy df R€sistaitun of NI nBs r r'(|d$rR rbch'd -lrlNo

F

;.- ] RTGI "'1.u1),')" l'+1,,*o.*

- -111t4:l l l5-J. h- }!. et 1", I.+

, " "",;*. oelDalon e"l nttz t"' n+)

" "' f 'ni;m

W:1:i qt i *, ^'"#J"i

:"u,1 b^\ 2oqd € a'6''r^^

r(bt Iobef'll(d in by Er Am,y Pci*nnelonly:

Nob,l lavelo! len mEideled in any UC/ItrC insP{tion ariny orherinstitutiotr/medical.ollege. lu r't Ld )\!.'\. nta. Ple..e Fn. d. h'l'.

I sr! *vrri"q rr ]l7ir" f? sctu/ -d *ric".J -,

mnr'ins /rreha;; /TraNrerins (R€li*ins odq is

.-T4s6

Numb.r or Resr.h publi.arions nr hdd Joui,rak:

5 (r) lnhn.tiomlJounlns:

5 t) shh/r,Erlutnn tQn cr_

r\rr PAN card No. b 4Fy Pk O5oo Al

r'ry.r.ar,., -a u. i, grtr a5s? l?lttI hrve drawr lotal enolunents frcn this alleSe in dF current linnkial ys,r js uMeF

^ Ac,6o/- lhnoo l-

[:191,

G,.^b". !,ii

A

D(smbE 2ol3

j;;*,I r"b"*" ,m,Mllcl 2m:

&ror 16(lD6le.irici|9nrf rincLiryQr20lT-lsrrs ra.h )

DECLARATION

.",r"g * Df,rfaltr, 'n

,r'"

", k. q1 ... T_un'lcdir'nB rhar l,m . lulL

.'i. woAi'rs {om -La.M.

to

I h.'v. not pr*nled n,y*ll lo any other M€dical College / IrctitutnD $ a fa'uhy /R.b \rn i'1nE.rif€nraQJemicy.ar forthc PurPoseoI Mcl as\smcir

I rn Dt hrri',3 p ivit Pmri,l.4iiywhc'r oR I rn rricri'i'rs at

. . - :: jn\he.irl or-. - ind Drl

hotrr ot PrrdiQ iru-- to :i, rr{her I naF lhar I ift not d{'i'Ig arv Pr'v're

P;rdicc or n.t $orkins inanyorh.rhu!Pirrl duri'ratulleg? houG

Complch derdils with ngrd h *ork etFricn.e has ban Pmv eJ & rcthi'rg h.s b€en

la rr sdki'r8i'r int orhe' neJi.il.oll.'|lr"ltontal(nh3r i'r rh'sriL or6rr\idr'tlt Stittr, itrr.rru.iiy: Regurir / cont,(rual/ AdhN--rulLt'me/ Pdt timr/ rtum'a'v

lu ir,lcclarud drt erch sLrhnent and/or (otrr.nbof rlis declaration ind /ot dNnenberlifi.rrd submitred .lda wirn dre de.lararion forn, by the undersigned arc a[Eolublt

authentic. In thc event .f anv shhmdnt made in ihis d{la.ation,ubae.r.Fnrlv tomnq oL, ro b- in. rdr o, fik $" unJe'5i3rcJ hr\ LndrFbod dnd

*..dJ' r -.h;.',1.< "i.'io' i'. 'r\p(r mal ronte''.o tli\ itrldilnon snJll dl{ b€

drr'l-t r.' nr"n8 rld rnd.''i8rnl hibL. (.r r(c$"^J.\a.'nr'ri'1'onl'NluJi',Sn m'-of lisra:. n'n I'rl'/i \4!J !rl lt.xbt'l

trq'.\6 - 06- ao8

sIGNATURE Of IHE EMPLOYEE

riND!tR5rtllf]r1

lh,s .idoFrmcnr s tlt..,ht,. dn rhir th. rnnercignel his silnfied hitrsell /h.iselIaborrrhe(vre.n*ssirdvem. yolci.hetrnrotrhisrl{lrioonrrl.ndorrstltibovrmcnitunfd di'aln is tu. ind .oft.l I hrvP vcriried tl]P .qiirkde / dmunstssubn,id€d by th€.'.dtdiewirh rhc originll re{ifi.des/d(un'enh rs subNnied by the

h rhc .on(.rned Innitut. rnd hrve r.und rheh b hc

any oihcricrivir! dr.I€colltsc s.rkins h.uF je tom g jllrt, ZlCli siNe|/she

lo rr!,.q!r.r rlr5 rlslir..nin k.m8.or trr ti. fitlN id'n\r!r i1) trr .l tlii5d.d.}.{il'r n'l\.91.iIl! ltr|ngrh,n rl{ trn\1.'!gi!{ sh( iLv,l,(.L,luLL! n5Niribl!,tlsmPs th! il{{Lir,st hjnrU/h5n,lr

_.Bd,c-'

I{iU4!!K!

Coune*,fn.d sith {in,r) hv ih.Di'.dd/r).rtPrhn0rl

>l,ri'nfl.$,sLsnr(l q l!in /

rhotr) lI) rrDt nnn,(t hvC.!r A Lnh.r il* : Pisstn t / rANcr(r / v.rdIn,/

^rdhr cakr

Ccrtifif cop'c ofp'$cntaptoioitrrnr dnl* I prt\un

copy ol frspoi /v.r.rcafd / rjlediiciry lr'li/ T.l.phoN lt,l/ ^rlhr

cr'Ll / Dpanlallooncfr lfr..rrlh.(l.ri rrsiot

coryorr,rsl,on /vorcr(iRl / li.drnlry Bir / r.LerhoN Bill/ /\llhirCrJ r((h.(l J5. fri,f.i, i3 Er. i , rL r4.r i i, nirrtr

$oIo$(, a' l,, '. nf\lrlJc-" 1rr, rLr$ ,Irr!,.,,[ h,,1, fr'rL,r'srr rt;.,)r ]

aot,vor.\pericfc..rhf (aFtdallre.'.hinBrtl]. n,.nrs

r r rh(nrs,,d i4f, l $'rr i .'lr'fl,r,rhnlli i,.tr! lr i, r,ssl r I , ,61

corv or Lr.c. Noiniz.d ieiher r

Univon\'..-.-Copv of PG Rogniz.'j €acheruni;dsitv.lroi P,G Ass$ne'r!

'.:\

'^ \!\li

8F"\'r""K'Si6ed bv rh. T€a(heir{D!c- O6-c,6-

sien€dbvrheHOD|Dlq t8-

gils!

ao€

-:is?tf*'"?:*ff'sl6.d & vllried bvthe Ar€sor:

9!!s-l!@

The Ddar.rion Imm will nor be a(ePlPdnnJ rhe pesan will nor be rcunrPd rs rea(her iI

:il.;i;;;;;;;;.."..",' "" "d 6iioled/drchcd wnhrh' Dtrr,ition ro'

i'lll"lii 'lirl ii'i i" *'.a m r k*htr ilrhe o ainr or nhdo Io pnior' R'siihrbn

ilifiii-i i iji'*i"i ii,,rrr."* / r^N c'rd/ s''te Medicir counrir rD rir h ed) 'P nor

Mdu.ed forvenfl.arion n therifi'liilli-i iii",.t.r thc revi.ed ddr'i{rion rorm in rhis rormd onrv ranv

;: ;,,;;;;;;;i " - ord rotmr $irr nor b' a(ePred i'd he wirr nd be enred

re'td(her')

2,

NAME OF THE CoLLEGE: I.rocJ Meb|cqI cOLLe6e

E"*-"r;

,N",.. r -,-p"".,iirih.r D*a "oo

*,-,r.y "

,,0.i, -,1 *"dltrilrretr rdD or fru rJ rhoF".rc, app-,edb,^.*.-.rn.n_);H'i[T.l i,t1ti:i:dtiil "&liltit't'lil:]i ":ELrLi) ,hr.dr,,h&^sc...31 03. 1q.Y6.. . ,{.lyRS..i (,) sul,,,rprn,[tDf""n,*,(nbvco{ Atr{rrtr]Lies:

Phob lD surrbided:Pispoi.opylt'AN cird/vor.r lDlArdliir c*d

N*,,r*, . 4266€043l:tt0.. k*.rby

* ]l

DECLARAT|oN FORM : 2019-2o - FAGULTY

. . So.vr. be r'ri ii.r.rrn' rB LrLlr. 7) o, Binrlt q'ir (ier,Do. Jnenr!^-e,,i,hd t n.t.,..o, .. mu{ b. ir fns,,.h

r.(1)r..

r(.rlv

r',', " oBt,I. TQri. 6JN.aoLoliLo,rr.g", - Ys04a D€n]cAL, G!La6€. ,r {o,Z}|rKo-bE

, p'*"rD""isid-', A(S l€.1a1.,1.I PR{\FesGrR (.ML{o)

Ce4iric{.opics ot presenr app.nrtmentor.ter.i p,6enr i,suiuF iniched

N{m d arpoirbncd (iI&-.1u ,r r / conbictuat / ^dhN(blt!!fl unc / piir rin. / Hono,nry-/ '!r1 ,, w l.Li t r,, tr,,1.< _ lro

Dir' d ippdkNc i'r r-sr Mcr ucr"crnq o,r,* o*.""".u,111$*nudrese traclt l|qDl4L-6r,t<c 6whdhs r|)Pere.t ent {epbd iD r_a$ Mcr _ uc/pc Asse$menr n he same

hl {1,r;,t,.,t t,r v.. t./whethe' you hav. rcft.d aror Cole,nnjenr ,hcdnal ..rc[e - Yes /_D]6 rf YA,

. s.*-

._CH€uA!r,a , ! o

r G) (b) Pernan.nt Rdidcnriat Addle$ of Enplot€ :

--|llKlrIJAMr- -a^ /4:., q{. C evAyur. p oK0rtItrln.

l.(0 Il re)or Lnda8o." I air'nr tr t,'.. \.r'\lvor.n^p rv(,.regjnJ(drndrMl o' i, au,,otl,gt -"t,a Rt4ont cn!"oU.rruo.ht1,

Name ol MCI Regional C?nh? r,heieTrahi,rs wrs done/rlrrdrrra tudr do,. ri.attcs., 3i1'( tht drtaik oIu(obpnt

Dtrtenn//la..ot bi n ng

t,t|Rt l

r(I, copy oI Pa$pcr^oter ctud/ Etedri.ity Bi ArndlineTelephone Bi|l/ AJdhr card/r(achedasaproof of rcsiden.e. yeg^o

r.(rr cotrrdr,,ntictrh* 1rr(ofii€), o^q5 9 tq j,(xl (-irhsrD..dc)

MZ

| (r)

IU)

Dite orj(,i,,i,,s p,ascnr iN h Lor, []aXOtS .E AsSr 9R.ezss.R

rdtrmrj r+D r rrr/'e pk*r I indird..{h.rrd -Jts/N.

aDo l €0612

r: -D60

_JSs Ho6PnLQGUHs 3w2L R6O H3

r jdsIroc$

BoARD 1-o rl & 62L

Notq Fo pc.t osffil qNtifi.ahon addirjoral Rcgisrdi.n.erti,crtc pair^ran ri htrrhhcd and\'r,., t\,fh1.tori' tj,, i\t .t,, r h, {rfl .t..,|l"

2 (.) Copy of Degree certifkarcs otMBlsand PC degree aha.hed -_y6rNo2 (b ) Copy of Regi$rarion of MBBS d PG degEe rhed -Jr-lqNo

3(r) Derairs oftheiea.tunscxperj€n.e ii dare

oBE loo l

oBq 1o rr- ao|3

o86 l. 4 .%|5 'Ltt dnt.. g YF,6,

Ii

*.'':"fi f i.i$l:ff 'f fi .';i!'J""-ilf; ;,3-*" " -,.*",, ";;;;." -*.

:uu',s -&;',rid;i'"'' ': i',:,Ll:, *'^ty _ unsPl?_ -

;:ii.j;,:., .," \,.,,,,-.,.s ".,i.;,,,s

;;;";',".#"_-* Hi" "Jl,:

r__-l

N!Dn!' ot Rennrh ptrbti.ibDN ir ld.xlournak:5 (d) r,rdrarionatjonhak:

5l r <ril /l' \ n, L , t,{L,il,:2.

6li) r\rr|ANcrnN. ( ALbtPv 4q31e.6 (b) N.r'

^et/r(itrrNo is 42GE&,as21tb.6. (.) I h,vedrawn hlitendon,""o Ur,,no..r"r",

I tlnuunrRe.eivcd

thcctrr€ntlinami.t vuras undcr:

l

I, iI:,.d.,,sP".j"j,",

--|. - -.-

-I 2 I chsiried sp<;lkr

l6I ti 6

6 l )lcop\ orr\ P^N &FLnnr5 (l Ds .ertifi.nr) r.r finan.ial

DICLAIIATION

/,4 L'\hn 6ovin.r -k tL _.,-r_s,. A<<t D6{.(.". ..rt_t^p.,r' 1,otrd,{ (r/.rd4hr d -kno!r

-

v.di,d.id". .r\do t.-rbr B\r dr uf,t", ilr.e rt , | ,r , . ,,r. p4,hq.rK]4(f: !lr,,s,,i,n _LAv (. 4 nM ,_,,,,

r.\.,. ro,n ort"r v.J,.d,!o ec . Innruhor,d,,,.utry,, r'o. .t-. Pu.p,en v/idvem!nr

I an nbi havin8 p,ivare pr..rice anlwhere O( | :m pr.dicing al

Lr.,rt,,.,,. r. ,1..t I .r.r,rh.rt i,...,t nl.r) Lir'r.fr.'dirornorrorki,rSi,raif orh.rhd\pir.l Juringm egchouE

,3, '. r! . rt "d,.c r, r , t. rB ,..' 'c 1

r , . '.u

s,rliru r n.r. | !. h, r...,.[!ac. h r.,,m ft,. A'Lir) R,du,{ L..r,..r,.,, ".t.,,.. .L[ 1.: , " ,,,n_ H., , .)l ':.1 :,1 'li'.(rfltr irrur.uhn, rr,r dt, n! rdl, L l(r,triion rorm b\ tt,ct,,". ..^.r

",.r ,ur"*ii ,. ,,i" *.,,i; ;;.;"i:;I,,'H:i:1l"i,il";::l:slsu!t!uq'1h t'1i'g td,! br ' unJ,,s8rr | ^ un,rr,n@J rt: ."d"r h.i r,h TFd.a.,dh,, r ,e.If I r. alr,conr.nrot ,ttr.r.,",. *". n , ,,- *

';,..1 . " qj"" rAmn,rhi .t,qeby Fnden,rs rhe undes.sn,d h,bt. roJ n(sarvorntnf,l dfo '('n.tJJin3 r tr,$.,,- h,.,.*er- t.Jknvcd..4tn"gbhl

rLr( ot oc, aot?In!g i4AitA<s€tv -

'f4or. t,ru^ e*no.*,SICNATURD OF THE trMPLOYFF

I

.J ENDORSEMENT

lhis r ondn,enr h rhc (ertifi.ation rhar the uNlersigNd has sahsfidi hi'nself /hc6eunhrr th. coft{hress ind vercity olea.hcontrit or thk d€larahonl;dnDd deladtid s huc alld cofled I hNe ve'ified the ceiiricar6/ doome'bsubnihed by rhe.andidate with the otiainJ edifkai€vdmunenrs as srbmitred by the

hrhd b ti€ ln*irft and wnh the concened Institute and have found rhen to be

,. l irsonrnm ihd Dr. L;< |' n 60(rlY\4 . k v is noi FradL.i'r8 o, crrvins out

irry odrer activity durins.ollese wor*ing hou6 i e lrodla!{b 4 DM. sin.€ he/she

hasjo,ned rhe hstitute

r l| dre ;cnr of this de.laration tunring out l,o be either incor*t or anv Part of thkdeLariiioi suhsequertly iurningout ro bc in.oiiRr or fake it is undertmd and a.cePl€d

rhir thd !ndeBisned shillalso b€eqtrillt rcsponsibLe besdes thededa'anthLnslr/hereelrfrrtry .hDrisdedi,itio,ormtditrm.rt

_9+y'D.ne C;? o6: IdLt counteNigrc(l !$ damP by the

DnNtor/Dear/Pri'rclPil

"Y;.,-;..,1;.,B.E!44!45

SrbmiitedRdani Passpod si^ Photoofthe EmPloyeqSrgned by Dean /l!i'rri|In ordrdlqjc r/n'lli noll) p,lorissucd l'!c,'v(

^L'rl,.riri!\: r'isst.d / PAN

crn / vorerrD/ r\ hii ci d

Ccr. i.n..pi6 o1 pi!.*nr dppotrhnmr.fde { Presed

-op)d

t'u.p"t / vot' ca.a / r|n.trity B]ll / lelcphone BilL

/ Arllw Canl / Dein 3rlkninrnt ld.erah.hed asr Proor or

-ii-i,d n""p*r ^,*.c..,1/

Elericiry rrill/ rehPhdrd RLll

/ AidharCdrd athdrP(l * | pnoJoi'rl8 repoit at ihc p'tsen"n*'totec@-i* .r D"+*d'k#' d M Lr35 a' d lt den@aop's vr Resi.Ed'or !r M BBs r d I!!$I99Copt oleiperier.ece,bfi.ate for all tichi.S aPPointmenb

held bdrorc ioiniirs Fresent LBttuteRclievin* o'Jcrhrn tl'e p'.vLous rNhrusor

Inn'lh(lr 5.! h(i.lro rr la'lr,r'il\kl..rto, hcrl1tr,(i*otre{hcrs$lrrr.p n,.$3)Copr of U C carIrizcd tcicl'..1!&rhni'rfiili.i.!]

P

+9>siened bv lhe Teachei!4q| O? 06- Ao\g '#.-*rtrYr"rr

PRINCJPAL

5,rned & \ €riftto4J (ma,6dsno2

P!!!l

!a!&

l$"?i;:ll;:::::t tlj.T! i: "::::j:"",T :I.fi it il: ;ij:,1;;1',fl 1. r.Fe, r

iilli#i:ir: fil+:i;;"1.::ii I tff .it'rii

il :::::,

"",|f

;l:,T,l':i;":;mu$ subnir ihs .evised ded rrion ford;.,;i, ;;;,;;;i,fi i';:":l: ;::;:i"T.ilii::.::il,'i"lT i:ii';l il,l;,til

c,11 "r

r c *ogn ,-r r-h; hh;i;;;iJ;i;;un'yd6rry.(or P.c. A-sesmenr

+\

NAME OF THE COLLEGE. K I\4.( .T IAPDI(41 (O/) PC,E

. DECLARAT|oN FoRM:2oi9_2o _ FACULTY' ;i.: 1.1-';:L1T:"1 "1:' ":'"j(.ri {on i on d rdut9 who h.s nor lpper,.d fo, N-e$h.d jn any

i,::''Tf",' jfi:"t:ruxi'F.;;ii% !",,'p.!

raspoit copy/ PAN card/vorer rDlAadhii caia

N".b*..1BlJ.:-. p,..L. y.p p k6d.k.:{

/

Not!: 1) wjthour rhoro tD, Dectaration forh wi!*P-"3 fJculry. 4 orisin:r ced,f,c €srern€kvDkumsrrc€dirkd

.c'6.r, D \isrrno, 4".,/z^l l-,i. c<n t nnno).rri1J i opa s olp'.pr'{ppo n*,

"-.,,." p,^*,

' z t uy* ** * ^ " t4k/,$, ^,,^

ist Mc/_ Lfclrc asFsn.d n thc ja-.,.'r.8. -l!tl

wndrp,,r'.' hd\.,-i,eJ rrcm c-","-*, ..a.,r,a..*" r^. ti, ro.

, #-.'' .^**;+"8ii'"'

N.rui! or ipAri'rhcnr (a)

lD,

x"g\d 4.c., u o.*, 7nrr,o.iii;a;,r;;;Jiil#:- -wtn - wirr..,ir p,*r" p-o,i"Er.t])ri

l.(e) (1,) Ptmanenr Reedenbrl Add6 or Emptojee:

J> 1..1-

Nan. or Nrct ncsro;;i-;;;;@ DdtP atd plod ol taat s

*"14

Ir ri^Es w s dan4 V |,*ifi B ua r ttoE.otrtsr Stte rnnnik,,t t! oL\trun

Ik)

I (n)

| (r)

r'{i)

N'@ .

:ij.isli:Til#iff:i:i \tu.lh rs.||/rid'im '"'ephme

u,,/ A.'dh' ( a'dl

coihd f, rhcutiE I ut (olr,c<l :

'trttRsi,tenel. a4{{, ))13hxt @ithsm6oe)

"",t r,"6- q qq y4.?€ s r *nd'u, rp

'nt p'e\e,i,n\hi hvi: O - 8- aor5 as

jo rS rcpon .rr rhc Prescnr us(utuaft.hed Yes/No

-hzu.t .ctt -.".14ir@t'ai&i'/rc)

D J1t,

I&,',lt

Prr !urns rr n rnured i' d

iT-'/r,""t..' t<t"-k J;l1n1lFtu + n u'tta"V I l<.,-la Nt41,fi!4/rr,1,v ;od3

fu,l tl 6Ll. - , ,) a/*{ I '!l 1""'7&ho

Noh: ror PC.fon PC q!rtifj.ahor addntonit R$nhiion certificaresubl(id b. ersc.ad! our rLhtrh.fdr is ndr aptLidtrtc

2 (,,) coFyorD.s^e.eiifi.ares orMBss d pc deEree db.hed - 6N.2 (t,) copy or nesisrrrion or MuBs rnd rc desree*i.hed - }aeE4.ro

:r l, Ddiikor rhc rea.h racxpc'irre bL ditu

lsrr ta{'r at -t -]104 14

t7.Jt -7-e'l

d Y4

€7t!cq

', .-.1; 'rt,

n'+d a7, ^'r

o*

I

llb). To b(fillcd in by E Arn'' Pedonnelonly:

t;; ,-,,"""-

l:ll"l "*'i]1'

LLNote I lavc !.tr L)L.n.onsiiritd

duri'rBli{1)dr6 lf ye5,n,air Ju IL rrir ',,r.r\orhp.'niru'r trrli., , lhb.

\-

relnr m< tuhon | $s korrms r r!!

/TFn.r(rnns (nelievins order is

Nu'nberot Resea.ch puuldinN if I' ci,ornils

5. (.' ) htd mridirtor n.'rs:

6.\b) y ^^,rh,,"dN".G 4 QAAJrPf.kS/o

6. (.) Ihrvc(lntr$totrlcDn(ncnlsfro'nthii.olleg.inthecurcntlinin.iil]ai'isund.r:

pL &!366 (r) Mr r.\N c.Td No. is 7

L!!111If

t l-

F-__.lN:ry 20D

tl

6. (r ) (copv.rrry P N&f.rmr6Omcedri.rre)rortjnancialycar2ortsr!areatra.hed)

DECLARATION

i'.j. ,,::'."""., n\.rr 1.r\ ir,.,r.,r dr .or.,r ,.,.nh, ..i..i..r,1,i.r,r.n...,f.,rl! pnrr in ({ I'avi'r3 prtv.tr. pj.].t(! trnywhcre oli ! dr pDdr.nS I

Pn.ti.e or iroiRorkins i,r artcon,fl0tr dcr.rilr with r.8id

b _.f_unr'er I nab rhar r inr nor doiq rryother hospiral drring otlcge houE

! $ trr r.p.rilr, his hrn fr.\ ,tq.l & nnrt irj his ,rnlfn Dr,!)r(nl| n rdlN D.\ti.i ..lt.s(/J.trratdtdgrr trr,\rarr.r or hnre rhcsbtetr, ,r!1 f.+),'riy: Rcfut.n /( i,rr.r.rr,r /^(rh(-.-rul ri,n!/ r,a(ri,n./ ]rd\r,r IIt,5 Ll.fh(l rhr cic| *r.i(d.r /!r(.i b of,ris d!{tifr _ ril /", do.,meng

!' IF l' i..lj It| | \ L ',1'' |oo,l "nJn...1.t ",

n,.!r, r.. .i,,i,,.n,o. | \d...,,,, t,. d..rc'j].''',.Ti'llia|''jil'.dl'||1'''1'..'i'vr.,,i,r,. ,i t..r, ,r,o tn,t, ,v,,,,, ,q.,,,.

rl

-i'JN =--e-o4o oe /oe to,o,r SJCNATURE OFTHE EMTTOTEE

€

lh i dnlrnrneit is drr Ntiti.,,litr rlDt rhc uf(le6,sne.l has silkrLell hims.ll /husclfihorrrl,c dnre.hdr Jnll{yr.i1l ol.irr (rr.rtol rhis do.h iiion ind cfdobes the ib(,vdin'rdrd d.da'trrion 6 bur a'nl .or+_i I have verified the .e(iri(ites / do.rnenrssuhnnted by the crndnl a with rhe original.eniri.ates/do.umenG as submirie'l b/iheter(her to ih. In$irure and wit rve round them to be

r iho.onrnh dir D, /,Ja^*- t. b Nt fn'.ii.r'u or .rtryf8 oul

ri).lrN ictivig ru'i',scoLqj.\or(,dshousic rro _* " 4,"*.r"r.ru

hr r'e o\ont ol this delahtior turni'rg oui ro b€ e her i'ronlct or any Part ol thisdddr'ation n'bsequenrly rumirg out io bc n'.orrect or lalse it is und?rsiood and i(cptrhrt ll,c undcrolgncd shali also h $ually responsible besidcs ih. d(larmthimself/herseltnninf ntrh nrisnc.larrrion o, mrniunedr

^t_27f'__- W---'5a,,rh\, \ Lrr) , .",'r',,6 s r.hnfb\r..

It6..nr/r)d'/lrn.FilCIPAL

5.!!eRe.. { I'jaspoi sz. photo oI the Ffrploy*,Srgrnal l,y De$ /

fhon,ll)f(!f \mllL\ Govr n!trr(Lcs l',brtrrt / PANc., ,r/ Y.'q 0),r

^,trrh,i cdJ

corr r.d qr.s.rpr.sonr iproL,nrHn i'dt' I Pir\cd

cofJ oi I'arspon /Voi.rCrd / flc.tl.irt, ir ll/ lcllTh!oe llil/ l\iJ wCiJ / lrd,nt rLllt,nctrr l{t!' atrehc! isa p'oot ot

copr or f.sspi{ / vdd c,rd / LllrrL.iry Bill / l tlcPhom ItlL/ ]\idhr crrJ irbd\.tl as i prcofoi Fe,i netrt'.s cncc

loirif s'.Pon rt thc r'lsdn' di'd.r f6 lMLiFS d lC lelr*

c.f e'of l{eqEtrihon oi MBbsi rl rC lEArcc

c.p) olcxpcricn(cd,fkit f$ ill tPa.hing aFPoinidedbhck{ h-r.ipioi',i,'r prcsent i'Btiue.lr 4 r, '.lc 1,,{'rlep'd otri Bhturi'n

litl' r l6 (los..'hn.ilc)'o tll- ri$ ridii.i.rl)_.r.Li,Ina (,r i\ i, rh.\$ \ r!fi!n Lr:)

dtrr n,n r,t,r..l

Copy ot P C rcmgi'zcd Mcher tcft' f-- "ff,I,e.dUn'veEiry.(or P c. a$*menrl

si4€d bv rhe T€cherP.!.. O6-OG-aot&

A Jtlr{L,./,ltlry:,./ &, \

fiJr"".!""I3rt ir0.fFll"^!"4PRINCIPAL

I(MCTMEOLCTCOLLECEMAt.l,ssEFYPo

(ozHrxooE 673 602

*--@"A;*

in .his format onty. (Anvand he will narbe.ounra

Sler

2,

IAIIjTh. Etedd*iDn Flrn wi nd be 4Gpled rnd rhe peBon eilt nor b. ounred rs tei(he ifinyor rieabovedocumed\ ire nor en!tosed/id.chd withthe DRtir.rion FormIhe peJ$n hill nol b€ relded rs a lea.her jfrhe otgnatof phoro tD prcol R.gisrhtionr.i,nkrG_r/ uesee e ifiok!/pAN cardlslare Medndl coun.jt tD rif kuedl are nor

AII the teo.hetr hu* subnn .he relhed d(trration fornd<lararion forn submlt€d in rn otd forh.t wi not be...epted

NAME OF THE COLLEGE: KM.T 14CDI.4L coLLdqF

I

w

r44 4 st'4]? 1{'/)< i Ar'r

r (.r)vl

Itl)viii

DEGLARATION FoRM : 2O{9-2o - FACULTY(Nd., nisrcrpo$ibnityofDqn, HoD &rrcurty ro submn dnlyrhsdrrriionlon ofta.utt who hisid apFrred roi ss63me.i ii myd rrorqc du*$rh9iedshjr.J",."nji,o*,ncs f,I Lmcr| \f ,rr: s nrvAr{/..1d^.

1l F.r(, ndrlt\sc Il-.rl-11Ya 5b Y.e. !ar.(L) strLrD'irfh.r' t!) pdof isn,!!]br covr. r\trrhd,i&1:

I,hotoID s0bnriflod:Passpon (opylp^N cr,l/ vore! rDlAadhrrcaid

N., r.", ?qro () 16 3ir tJ r.. 'r.rhy covr oF l.lDlA\ur': l) wrrhur thoro tD. Doc.r'r'rof, form (,.r bc,.je<Fd.r,d witl!l. ll.3 tu,u-ry 2r o,isin,. mrndro,y rur \cir( or 4.1cdrifi.dei^rounsdycqrified lridriions, mu* be in tnglish

r(,1)i

r.(r)(i),,

r N)ii.

p,eirr Desis,i rion Asst<TA\tT PRoFE<to<

a,"fi,o!,o'p..'pr.,nrit NiTmer',rde, o.papr,rr1.,hrr h.,.

rrp-i*"r a/3( rFTe I c 4^to 6V^t,t€colrl,1

c.,,qj", K4!f .^1@re!! eqtlsLfc", .Ko? l\xllEN." ', ,, -.,,,,;:,! , ",.r". , ,, Reu,/r4f

ih,|.T1,, r,,rr. rof ,-. -trrl1 nd-r.lhdt.o, L\ft nrf,N.iR t1..'i- vJDlolI "

r'.r'.r.,luL{ ! rr.,,rr .!ic \a!urlA!. ....,t/:lE.-r,(,r.s. K4^!I ^4L-DI.^C

C,LL€ 4 €r\rl< h.i .lpj,!..t .

lvhr' ,Pt-4,r \'1 . - | 1- l..,*a,,r r !"ne

t{h.du you hive rcLned rron covcnncnr medi.at coiles. _ yc / Nkar yc,

ii#"F'Jl[?hiqr

Nahe or Mq Rd;",iG;;;i;;-tnn E wx d6E/ V tunth,x ure do,te i,l

414 rJAs (e R

sJlE k{E N4TAiA

'LlD"te -,.r pt;;G;;G

Loo \4

uk

trLll!4!urtl3l]!!:v4!l1 rar rr.q .,qtl9lro

^to 3-'Frr5lrol prT: SHtuAlt

^tqtaAR

he q4

ef tor (r) ni\r you unLl!rtu! T,anj.B n.tsJj, C.urseh.rr(F6...,n\ . or h ao,,o,4. h:.,t,., Rz__iJ",,*";llllf, ",,,i.,*o *,,.*"

," t,xf s *, n,. d,tii t, "t,: "i,; ;i,

;:ll.'i ii.Tfi#ii:: i:l1j iJ^,::d,r e'rr r,'0''n"'"'ono,p a,,r, 4{,,n,

conh(padicurab rd (orn,.e), n 44s- p{? 3 4 3 t __(with srDc.de)

Jr(g

1 (h)

r.(t)

I (i)

PerhdentPey,jenridt AddK or Emptoyee :

am,f,,ihos 96gJ . ^4

s 6.t\)

fT^4.oLtE r €2l!, !.i €4 r

KUH'

R

s oo7

f-vv"volrli/I'hD dott rcM c.9Lter^ t t43lo I

La^''Notu,

Illl T :,ls:lic q."rrfic"tion add irionir r%istniion .en,ricrre pani.urire b. rui,,ish.d andsrD,(r bearcr.!rrjnB onr whj.h.veris notappliLabtc

2 0) copy ot Degreecedificars or MBBSand pc desreedr&hed-V-es/No2 (b) copy urResishaiion ofMrus ona rc a"g*.,,o.h"a - %d;3 (a) l)eraitsof rhe reachir! experiencc rjJJ darc.

DDATMA EtPedence

i +_!!!!!Lsl6laah )3yeAAt11'111"

m{I.J;i*;

aB9q^^.l(02Htk00E W.

o89t0\

q&ck02lfikdDE ? lrJaor,' r? lrloort I Y€,T A

.r..{r^ C602-IttkoD€ e, hl{ott arlr ltorr 5.4o^rrl

UV\ ,sl'laar

or l-r-41{4}r

3 ,I 3laou

ILL MfET 5 Mbrrtl. I

Tob€ rilled in bj t' Arny feDonneloirlyr

I Clrsiriedspccialhr

N.tr IlavrJ!u b.cn.ons .,ul(lu.i'rtl,sisyca's lf ycs,

i'r any UC/r€ insp.{iion at iry other nBtituiiof /medical coll.ge

l'4r, dA A('o'c,{c .oql qa," r, _&'IIAX.a h4]\rll1/

A!('(rA^n I{OFE rro't . rr 'r'. r' ' "i loslral6 aIFl

'-ra,\i!nira / ,dtrLis /lr,Nrdrirs (Rclievins order is cndbsed'rroh the Previous

NunL!. .r R.s.irfh ptrbLi.r[orsirl ldJ(uDrr

strte/lnn,tutionil lournah

6 (,r) N1! ''^Ncrd

No. f r&4q8i4tt?-F

6.(.) I $cd'8 rdrlcDroL,'nr{Nsnonrhistullegcinrheruroi

\

rr (.)lcoP| or r l,^N & Form l6 (lDsediri.are) rd nnancirlrea, 2or6.l7.r.irh.hed)

DECLARATION

rD, Sl{l\./Al urlAA "- *o,ki,,s ,4!t!4!L1!i!v'1,,,"

Lr.f ..f,rr.,, ,,i o8q i k M.f.ll ,. ,rJ\,r .r 1..,tn! r,iC)tr(^ DdP,l{lM € ^!T ".1,,,,,.S:Or^\r ..q:0r,.v,r",.)

,l'',:'''!:']:|]'''"'''ll''''|'1'l'''''I iD noi havint piivarc tri.rirf afywh.rc OR I .m piichcjng ir

I t-.f. .iB!|so|t)]].n.cilloFo'lher|sta1ctlI.lf',i(n.or for rukirg in an! ottie, h.spiiitdn,inSco leSe ho!6.. Ttlor,Ju.\ w.rh

'p8),. b \.,r ,+pp..1. n.r tFel t,o\,.r.r &,.rrrg t,. b_r

r, n u,wrr13i, r./.r!,h,r'r, .. ,3d oei I,n dSp,nhe,_ hne t. _1a. hr.d)

jl i!.|(Ll.rcLl thir d.dj si.n.rjfnr r /oi cof$k.f rhs d..hh.on ird /., do(nrefrs,r|l d!.r,f i(, r nnD,lrJ. r]re undcnisrd rf1,.rt]sor{eti

n,Ds,l ! {r 'i

i ',9

i. i

,,..,;" .3'-. r\.,'u r..,,.,n\,. r,,,,TtrddrM,,,.,td3, r.1.

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oe/os/ 79,q4^{A srgRy

\\.i,tt \.,,!,q,i p t,., b i o. 1 \rt-,d.,,,n.,,,j. rJ.,\,..rf ,b.."I h"ve \qir eo rh. te,r.f,!JF\ / ddumenbvbn d'oti d\ rhe ond.,lre *nh r1" o, Sinitce,rirkdevdo(rmenr. d\.ubmirted bv the

rearh, I ro ,he Injiruts Jnd o.r In{ird" and hJ@ tound rhen io be

,. Iar$n'rJtn,h*Di. S H]VA kui4A( is no' pachfl n3or.a'ryi,,goutd \.,.h", & n'n,rJ,trs.o rexr..dr,s r.1,, .. L r lt+s b

,n rh {rl oi rh.s d{"' rrc',u'rrg our ro b! e.rh". rtu,,efl ,, 4n) pd. o, rh5a<h,4mf .u6.nkdtr ru'1irg o,, ro o. d.,,,e r o. Lh.,, b und". rod dno a(eDr€rtrhoIr."LnJ"\iAned\h,ttatob"elrthFpotu.o.cbr:id4|hpd(tdii1rr.met.,Leis

66 / 66/tg cou i.isi3n.d Nirhs(anrPby iheDnlrb'/D4,lf , iD.ir,al

,. ::ll ll:ll;ll*FllFn@ao rifl(lopi6 d prsnr irppomu,elut..-,r lrMcopr .I pdspo, r /voru ca;d7 tjl.1-tr1;G-6n-ti;d;;; Bitl./ Ainharc,rd / Deint i ohcri t.{., n(,chd o";p,oorur

i.pti rsJrr v.L,,r.t/t.rl q b,lll,..,ot_or"Ertl/

^adrrrc..d a(ichar ar d proor"rpoiia."n *"ije._

1 lorr nx Gpri ir rhrFrs.r irrrurec {(! uf percr{f tK.is nr MBr9ih,t .c,r.s

7. (_"p", r R"e"h"h,,".l M BLS,.,,1 fc .r"!*.,,ry or e\pen!n.e.en't,.rrg rof arr r-t,nilprc-ffihgln b.loretotr{ng prc\enr

'Nodbl{e ev,n! orderircm rtE pr.vrous Mll Io'm lb(Tps.e hft.ir€)for rhe ttuiri;;;t!c;

r.rh. r"-.,,r (" , *d,;J;;"r* p-("-s)alra,,IUC t.*rrz k-(,!, t.rE.h*.lr, ,J

copr of Pc Moln;JE;fu;|"ft;k-;m;i;;!r\c^dl (iorrc A$esmc, rJ

sle r 6 16/ dat{ sifled bv,helopr&!cl o6-

Sirq

2.

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iiliji:'i"."i ilEil.:li:,r:fl :i".,.,f ;"fli:r ;l #i.::,i#r,""'i.:, **"

",ne pson krr mt be omkd J5 a terche f rhe orisirul

;n::r.::nt:":llr lri ii:i jll jf ri,s#.,"f :fi :i,B t; i:l.s,E'lr:,.T

il ij:"ji1),t.J;lut ::lt:.,:I";:r;:l_:i.lt,i:1.::;t.'t.Ji;;:ir;,::,:.J"il

N@&L1646

-,-llNole I ltr5rc5PoD5ibiri9 of Deartd.rlirer,o1r or ri;rr hhof,.rc' rpr4;dro,A\ 'nmi

dheroleecddi"s'\ceadeni!y6rair wdki"8 *Iull'rm4r (,r N;;" - DA.. tA 5EE.H A-, I E

' (rr) DdeofEirrh&As. t!',-'.

I (.) srbd,nPhor'irD ptuofissuedbyPhoo tD suboised I

rq?3... ..

oEcLARATtoN FoRM : 2or9-2o - FACULTY

Nole t) wiihout Photo lD, Dedrnrion for will be reieded rnd wili n.t b. considered asfrculry. t) originil ccnific*es re d.ndatory for vEriticiion. All

.pri ri.r.tDo.umcnrvcedih-d'f n4itions, D,u{ L,c in Ins]ish

, r]i,.n r.r8n L!, A 6st1tr 4

F6spn ,rpr/f*lsciid/ vder lol aairh#€dd

Nu,L,,r lcv . .l+(.-99 f.8 ; rsn,ed bv

Cfrtified copics of p'$cnippo ntmcrtoder it p,e.ent in*itu(r(rhcr

Dlpilhncnr A BJ16 retcJ .L -6!N4e@reL!:c.t,.i,.: kMt't Mljrtc+L

lrL

i r"4x*

r(r)".

N. P2 bF Ft. La-

Nirtr'! of :ppo iriie, r (,,) P%ulir / c!nh{tu.1 /,\,lhu.Fu Limc /c.,f hme i Hunodn. +{lll :!\ih ( r htrrL ut fn\ rc fr <

'\ro:l).i( .r itf.ih r..I I I.n i|l( l u(;/l{i//\nydrr.r. kj^cr cld{!I|a,..wh.th., ipfu'.(l d r(lplrJ]n ldd NlCl -

",,.,'.....,1fr,/,d.'"',,,,',,."

wh.Lhs ipplr(al aid Rrpted n Ltn MCI - UC/PC Ass.ssn(it

wheihci yotr ha\c rrh,rd fro'n Covern!trr mc\ii.il ..leg. Yas / \o lf Yes,

,Ml*fr

P6entResidenrial Addre$ otemDlovee:TvAt taoA r)Afh t+^n!t:EletJ.aN..-,yLqz-Ly_ h

(! LtLtt-r.

I {e) (b) Ponanent Residenfil addiess or Enploy€ :

al. .,^ 4|a ^

L.

r (f)

rk)

uderSone TEining in "Basic Coue Wdkshop,, at MCI Regiomt C6beot in yott .oU.Ae utuLt R.gional Ccrtte obs.ieEhit ?

MZ

Oate ,x/ r'lr.s oI vainin8

copj of f,$pdt /.r/dtr (xd / Ettrhicilv 3i / rndtjn. felephone Bi / AJdhr.Jrd /:tr:.hed $ : D6of of residence. r.r/No

r.(h) c.rtdctparri.ulaB: Tet(orli.e):

q_+-Lt$,hsrDro,tO

L mirralr,rss, sctrc,LaciaL./ 6fr4t/. @h.Muri eNumrrr qhqS 6" 2s 2o ..

D*eofjoinins pAeniind trtior, l-9. Ao l+ - l!{s t PC.6P€s. a.(1)

0)

Namr.I MCT Fgi.nilCenhc whftt\di^i^awas d.ne/ Il tni"htg uas darc hl@tt.ga siv tttt d.taitt oJ

'e obsNrut

,oiri,,g rcpod at the pr*nt indiru" "ur.-r yVG

tlc ql

-'€"

L,r

1 cn-d.6tLt oA\d. trl b aJiJ 61 ,

/PhD Wlt rA4sub,<t l.in* d

-l !4-Dlll-uch l?.D,t .,rr^O f.('nD &d."o,dgv&,16[+ 14r"

GLul-.lroorj .z,l-r(r

lricJrrJ l {bo6l {J-Ja9. l Boowd. i

NJmeor l -;;rns.itorion IDDATM/^Y

ro I ror,lDDAN4/yt I hpeien.e

2o i+td,t daE J. I.Yv <1

f-I

,

rb b€filted in by Ex Army peBonnetontyl

FY Insiturion t-. Plltsd

I'Nor. itivct.ubfcnconsmd?!

du'i[utd3yc].s Jr),€,nary Uc/rc insFcdbn airiv other n$hruttun/nc.ricit m ege

/xurldr

Nonnd d Rcs.dr.lrrubliorioN in hrt\ toutrnkl

5 t') r'trnariona|lotrriits:

5 1r I \hri hrirur N l! unr, \l

ibn.r I Ftu egp r.I ie,u,,.r...nif.,n y, d a. J.d"r.

- Amounr Releiv(d

[lJ r',\N cid N. is JD(I __p-s j 4 q + ov"n.,n".-,,r r. " .4191293? 5Jo6

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lury2013

seprcmbe. 2013

-$:##{"trs.,tr r.'i',xtfi :.*3&iii'lllll,i ..,',-* /rahsreiiins (Rerievins -a", ;i.n"r,*a

k

6. (c ) (c.py oI my PAN & Fo!fr r 6 GDs ertjfic.F) ror rina.ciat year 2r.rrct7 arc atra.hedt

DECLARATION

r. '.ur rar..M . r.r rmworkirg$Dep.rhenl or oBc. 9 r.VlYf atcorrese .n\ do heFby give an underha,ns ihal

La.lr rn_L

5,

r have not pErnred myseU ro atry ortrerRlridcnt in ihe.ufllnr acadenri.y$; ror dre

r am noi hrvina prjvare !a.n.e

Medi.al Coll€8e / Institution .r.a facultv /pulp6eotMCl@menL

anywheP oR I am Pra.irtinS at

nouN tr pr.ctice arc_ io _.Ftr,rtrer I shte dlai I dm nor dorrS anyPIa.Ii.e or not workinA in any orher hospitat during coltege hours.

ramnorwo'kingindyorh.rmed..dlo +e/dert tro e3ein rtesbForoubide+"srabinanr trpd.rry: Re8ut,r/ conr,(ru.r, cah. _ ru ,i-il p",trin.r qono,"*Ir i. .del.Fd .rhd e{h \b bm.ri dnd/or contslB o. rhF d{ ta,.rion md /f dtru menb,:*r.:y-,1!1;""d.:r. 13 s ,rh rr-e d.. r.tr.,1on hn. b he und{s.srd r e ab$ru Eh

:.;i:;Tffi il" il'l,T':.,i l: ;::',1 "'.1;1;',f,il:il.Hj';1 JI.ftiJ":::icrF( sdq(h tr nn^ tn,iD,r ,,.F,r., ircnrdorrhts,ratr.dhonsn. aLob€

;-$i".*,".ifi i tff lij';'.Iii :t "i:Tj;t,-1fi "tf ili1t::, #:i:'-:' "**'

This endorcemeni is the.cnificition that dp underci8ned has saiisfidl himself /he6elfabout ihd c.r{hrss md vera.iN olea.hconhntot ihh d*laraiion and en.{oBes the above

'nentionen declaration as tue amd cor(t I have verified th€.qtiri.d6/ dmumonb

submirted by thec didate wirh rhe original.ctifi.ilevdocutoents a€ subnited by lhsreacher to ihe tNtitute and wiih lhe .on.erned In*nut and have foud them to be

rarsoco nnthdDr. -qA A €CA 4. P.? is not phcticirs or .arryin8 ou r

te9'

any oiher aciivity durinacouese *dkr.g hdB r.c from lfuho - llP me he^he

hs,oi'Ed tlr lndiruh.

I I', rlr pvcni oI thk ddl rriof hning.ui to b€ ei\her i'r..nd.l or inr paii ot rhkdcdintol subs{ucnrly tu,rirg ou. t bc in.otrd or lik. ir is undorsbod i, ac.eptatthil rtu rndlBi3md shaLLako be qurLly

'espomible bend.a thf (lG artnt hihself/heBlf

rorrtry s'.h misde.lr(titl or mhsitc,nent.

D-e 6. c,. L .'

.x,lr$t!u:'

(,,unrb8ni \rh +rnrp by

5&ltNent l'rspoi sizc phoro of th( linploye, Signed by L)tin /

Photo ID pr@l irsued lryGovt audroribes Pasp.rt / PANca,Li / voter lDl aidharcrrdcp' r ied copie oI pscnr appoi,ltmcntorderar PEcnr

copyof Passpo, r /vor.rcrd / lledLiciiy lJiil/ Telephone sill/ Aadhrcaid / Dan'snbhortldErattt.hed d a pmlol

copy of Pb$pod / Vorcr card / Eledriciiy Bill / TelephoneBill/ Aldhar Cird attached as a prcof of pcrmanent ieideMe

5 l.ifiis rep.{ d rrE p'6!d in*itdccopies otDeqreeceirili.atesolMRBSaid I'cd.sreCoFics ofResEhahono, MBBSiid PC desrec.Copy !f c\trr.nce.ertif icik nr ill r.r.hi'rg ippo,ntm$$h.ld $nne oDi'rl presedr i,st turelrrl(!i',s,nl(r lr.'n rl. p !\i.u5 i'Nirtrr!, 'Ii' 16(lDs.cdifi.aLe)forthcli*airanci:lyeirl.'rc rnJrLo.i,."r rcr ^$h,

drpru!r!ing)C, fvvr UC c g' v<J rcdl'er elcrl, mifnlarLJ

9

9i!!!! !rl}! !ls!i*# q!!! i

^w:;r:1"*,

l f r lt, D,.iion lo'n' Eill no' bc rrcPred Jn'l I po$n t ll ro' b'oJTcd + krh'i r", ' "' ir. "u-. r-,-*r.." "or

en.:ored/ rrr(ted sih 'h" DednJion Io' n

i..; '':; ;,,i ;.i ^.....,"d

s " 'erhe' i'

'he o'isrnrr ot rho'o rD P oor' R$ntr'iion

i!l,ii.*, o;*"" *',r'-"" I rcN cr'r/ srJrc Mcdr4r counc'r ID nr h<ued) re nol

oioduced ror veriri.aiionat rhetihe of r$essment,. i ;;t;;ii;; iJ ""u.i' 'r",evised

derrraiion ro'n in this ronnd 'nrv (Anv

" i*r"'"i:'ii.,",'.'uir,'"a I.rnold rorm will not bc i<epiedand hc wirrnor be 'ounted

C pJ ol I'c r&ogn'zcLl hJcher Le

.:..;t#,;.'-.

FE' NAME OF THE COLLEGE:

rNoro: h is resDoniibilitvor Dcu, HoD & h.ulrv io 5ubhr onrvrhedehnrsi fem of fJry *ho h

r! N-.4 ,nR54^4'l'I(b) Ditr.rBirth&Ase Ia.:.9.t... !1a6... t l?dcq$

slbfiir Plrl$ ll) proof Endl by Covt Au rhonries

Irhob lDsub itied I

Pr$pon .oPy / I'AN ciid / voter tD / ^trdhJEdtd

N!-r", .5s 6.8 !,!61 e?+?. r'*.rL'.

DEGLARATION FoRM : 2ol9"2o - FAGIILTY-

Not.:1) Withou( l'hoto lD, De.l rrion for rvill bc rejed'd d rill nor

r.,.lr"s 1'.ulrY ., o'ig'nrl, a|, n:kr,rJo(m.dr, 'r.r'(dI

Jnlr'on' mJ{beirr'gr15

r(,1)'

1.*"rrr."$,,, !5riltqql 984!a!aediiidll copi.\ or Pies.trtipNinhcil d'dc' at Present ns(rk'ati'h(r

r,-,+-.,,' o09r e1R rL s

r<N.T r{eD r.D L

R(S,li / cdt'.'.hln./ ^.1h.crL'rrtln./r $'ie /b. trxtrv

n'iih or \\ithotri rrY'c hr.ti.r

$

94

\rru .olipp.i', .r: ii)(,('l

whlii.r appedtod .l a(+n.d D Lst Mcl uc/Pc ^ss'ss

enr m the samc

r),ft or.,pp. in& ir ri{ Nlcr uc/rr/^trv orh!' ^$c\$F

( i'hl4ln whi'h

LC/i\.t \*$nri ' imr

rvhedr y.u hiv. ,e!d hon 6 Lrde - \a / ]9'lf Ye'.

}ar€f(sc i kd,le i.,t

^JJ(nrrc,iuto\(.i8, ltuf)o( cA 9 ciicir !:!!! 91oP(")

'lr0 l\rtAgAj g,{45q

| (!) (r.) fu rn:tunr P!itrenridl \!ldres !IEmttoyrlI 5ulaRt ada ', fc!ordl fa{qA^/u4.

| (rl

(i)

NJn ,,l MctnlSr.ndtce rr..!1h!rerlainnt.^drdak/tl In \ a\ ttrrr.o ,aL gitc ttz ttdd , .I th ob'etuo

::ill 01 l!+pd irlole, .rd i '.

..nki) 0..r.I {n,Jine r-.. rhor b| | \,,td c{d /J|XhcdIJploo'orrcaidenc('\u'No

\.r1,'."r1(.n.. r.r.o..i sq s5 4!lt!j, iqr\ jrL,fd,

u."u"r,r,-" d,l """"Er @rl ^.,MDbileNun,rrr: q1+h11q<fL

Ditror|-n,nspr6oi^htuhon isil r, rg *ronrn8 rupod at the prccnt insjrde anmhcd JrlNo

Qurlirkrtion I collcs€

[.'] d,{-d

lGzY.L. J"

"iiiTvirlru I c"tt ri,r"l,",J,?ll', n,oi c'r"1.'

"*,!:,"19',' r.ru-u

I c ri,?ur!rrc4r,1v I aoro

k?a..t l-o,r- I q14;9un uc{r'l{ o eo9 ,_01-1ci6! goclu t( Eiag

1ip.,nt6na -

f

L:

I

rr. r'..cr\, rc. "s'., ,or.,or,,rtspdiit r.n.L-,, ,j.rtrd io<u! !1r b! ir'cr\v,trrsouthhKtcvc' E norippticrb e

2 (a ) copy or Deg.ee cedirkates or MBBS and Pc d.srec ar&hed -JrrNo2. (h) copy orRegnkatonol MBESand Pc desree itrach.d -J4No

'..,.,r.;, tt .1 , . ,t,,

oD/M^r/w tip.rien.e

;1;i;;;la;',t,lia- u'*

5 *"trq

Tobcfilredinby Ei Army peBomet onJjl

Nore Haverou b€f co,side,€n jnany uc/r€ iGpectionatantrJ ry c|veaB. r16 ptm.eg,vddddl;

oihe nshtuhon/med(at.o eee

Bclon j(i'nnlr fre$nr i,riihrior I B.r $or[]ns ii _rA'arr8 / krninS /lDnderng rRetievrns od€r

Numh nl Renfth puLitir,t,.ns trj

5 G) tnFrn:honatJournakl

5 G) 9bk/tn6htuhon.ttorrnats

ie en.ro6ed rrcm rhe prcvious

1Lt9L1 3J9tu

I hivedRwn br.lemolumc;b frcm this.oti+e i,, rhecurcnifinariatyearas uid.r:

La!!214-sa'

Sephmba 2OrB

6(c)(copy.rmyPAN&r'oin16arDs€rtiri.aie)rorrinanialyear2016_17areatrached)

DECLARATION

I, DI "44,Aru4I\

in $ ,rrmsx 4;lt!!441 fio.se.!! i rheD.l..rtrndi ,,f 04!l!:141!t !!19!o!!!jl it - kd., . Med(alcolqje .n\ Lr. hc,ob] 8ic an rndcftkins rhat r a,n a rufl rin. rea.her inIdrl d<D'a @r(ch6xd.1 rrcl')'tA, @!.E6. h in8 Inm jLA.M h .{._ nM dJ,ty

.,!,-. o,.hPnL.n+ or\4\ td.s.n,nlI rr noi hrvrng priv.tr pr.ri.e .nywhere oR I in pnctici.S ar

h.u6 or peciicc aie_ 1 ro - Further r srale thar I a,n nor dorrg anvPra.h.cor nol worki'rSnrinl orherhGp aj duiiigo gehoureconpl.t drt,rils hiih rc8.rd r. \vo,k e\Fri.nc has b€n p,ovide(l & n.rhn8 his bmrai' no$vorkugin aDy ortrl trrdl.at o $c/tjenLn olqE. ir dl'sratr,or otrbidc !|! srrbr r.,p.rcjir R+ular/ c.rr..r,atl Adh...-- Fu ,ime / pa*iimc / H.(rarylr'isnehBd irut och sfidrrd aid/or corrcnb or rhB de.taration itrd /o, dmuhenb,erhfkds $bmitbd .lm8 with rhr d{taration fornr, by rhe un.te6iSned are ibsoturety

aurhenh.. I'r rhe cvenr ot any $drement madc in this dRlanrio;subequeitrr furni|g our 60 b( inroiie.r or ra? $. uincsi8ned his trndeBrmd andi(epr.d d s'ch,nMmlr:tnnr i,r,.sFd tu,rr),mnr.d ot rhk d{.t,rnri.D shi| at$ betr!ihir + i g'cs nr:!rc,.r1.r rt.,."L'\ ,1.,enL rt- J't.,,.drf t,.,td L, r .v.y.' (rt .n.rv 4 hJ" ri dL i"A FT. tn of thl d np Lom tnd dn Mlu ?e,: vt,.

9IGNATUNT OF THf IMTLOYE[

ENDORSEMENT

Th., l,,ro,yn, "'. 15! . c.,t,,. rcn r}r ui, r, dq\ 3 r d I r: s4nnipil h m+tf , he,ftl

0..?,l,.o rtsd vr rni. ap ta,r o I i.J eldo^p! J_" r@venMrioNd dchiihdr 4 kue d c.tu.l I have veriaied th. cirificar€s / do.umenh{bmnkd br rhi ftndidrc s:rh rFo o,iS nJt !cdiricarey'ootbh!nF r. bmihed b\ rh€Fxr.. io rhe rtr{iu'c dnd sir tlnrrure:nd hrp furnd rhem io be.orud rd aurhentic.

DALSAIVA:L-r nor p,actici,r8 o, .artyins our'n.urlr hr'h!,nn',.,11,s, "..rrsTh.,.,i.,m I -

r,,r '-r1r of r5',.r.t.r.iii r_,,.nd. | ., l, di,\e, 11'r,or 1J' pdn.,.hr.r.,i/ nr i r,b\ r I' rh ru'.,3.r. Li lr.,,-., r."r, d r i _.r, .oni.,nd d..err{uD(ri J.i'\31{,tl?' r, t^ p!u".r,.,mn.,btro.,d^ hd Li, r.,ni,r\.lr nd el

6 /6ll b-aaf>-

Pa!!4

-

i:lil::i:iil"'.:i,:ll'''"'"'m'ore ss'e\rbvLtrd'j/ 5// \o: l'hob ID prool issuDd by covr. Aurh-iij* , p":stair i;fr

cad / vorer lp/ Aadhdcard J./*'c.niried ..pi* or p*i;.pt;,d;;i;;;;i pG;iror\, I riqp,rrlvorrcint/ Ft!.h,.rh B, /t.tcohoieB,tl/A, lFrC.rd / Dca,rsilornlr|eflcri(ached a5 i trcot.rrnf, r, ri!p./ vr,!r.i,r,r/ nrn\u / etrnl n! B,l/ lrdhafCitul atrddrd.!s i pjlo

-)o' / t'

%/N.a!.L

t1L1!

j"-s*p-,"riNr.'fuc"p"- .r p.s' * .eri "i* .rM BE;;d Rr ,[,N-c 4!$ of Reaahiioi,,1 MBBEd,!t pc,l$re!.py.rrlpencn.e!L*{rinrori tr.hnsiorvinhenE

R"ltrqns" rr rr"- ftrc p,c,(,u!rtrnr,h

Foi, rb(tpsedi'.irelr..the ;t;;a;ry;l,+r' l,-,i(,"-*"i k*he""1.;*p. .E)c.fr.r u.c r{oenrtJ hahertederr;m affit,akd

(i)p) orI'.c r{o3nri\t reachr etrrrro I arfitrat.du.r q5irf .(,or P c. A$.$nreft )

sPmd bv,he rcJ.hs /41d"*+D.r!!, b 6 t,;lY

sisned & veriried,Pv the Ase$or:

q!!! i

!qI! i

The Dedirarion Fon wilt nor be iccepred 3nd the peNon wiltnot becounted as te heriryof rheaboveddunenr cnotendosed/ rrh€dwirhtheDedarrtiont.orm.

Thp pe'{n wnl mr be \Ndpd ,. i reJchrr if rhe o'ig nal oI rho,o tD proor. R%i!tr .onLen,r(rc\ / ea,ee c.'tri(Jre\/ PA\ .rd / SrrF Medi.j .oun.jt jD ,ir i..ued, r. norprodu.ed forveiifharionat the timc of rsesshenr,All the hacher. nusr sub ir rhe relked dedaration torn ih $is foimat only. {anydclantion rorm sbnilled in m otd roih.r witl nor be a(epred a.d he wilt "d b";ou;dl

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.1.

NAME oF THE CoLLEGE, kmct fiteo'oe L coLeae' e qukt'on

DEGLARATIoN FoRM : 2ol9-2o - FAGULTY{Norc : Ir is rcsponsrbiri9 df Dean, HoD & fa.uly io subnit onlr th€delJdionronof'ad|tywhoh:

dhqldkee dudocrhea.rdeDKverrild worrnc.slunhnclr r") \;,. Y{.:-^aDi ..j.€,.nlra.i.1...1..

. 2L . a t- ,a t1 Zo rc4aJrtbr Dd$ofsidn&Ag

-)rk) suhm fPhoto LDprmra!"d bJ co\ r.

^urhonhcs:

N,-r,". ...917-J. '':qs:..t.911. r,,*a ry Y1dA.i . .l::..:1:.::iNote 1) wiihdt Photo ID D{r&aiion forn witt be ciKred rnd yill nd be .onsidered itr€aching faculiy. 2) or;ginal cedificar3 ae nandabry lor rcriEr,tion. AllcetificrterDodmedq/cedified Trnslarions, nu$ bc in Engljsh

. ..,r u.ncnio, D-9 <'a.J' roa a+<sa.<

1 (dXiF cedihed copi6 or pr*nt appoinhcni order ai p6ent iroiibre aradEd.

r.(d)ii. aoput nt' o9SaLta t eg Aao 6vNct'ctoq/

r.(d)iii. .o\t,i:,, kricl MLDttA- cacL44e. nArl4<cua9

- hukkoD

!d uJ.or,ipo r mrn: i i' tugJ " ,.,^,"r1"*- O'-::1Y,brILrrom, /rrrtim" H,^w; 7-;1 r.e,,.h,bow tidIf"r,"f-.': ;--,)' th .fu':.

.olllae ror( taap^<4.t aLePPe'

ill;I,:.gg"'" "oFo rt!'vil- c''A$snpnri 6cqr"l^l"ho Fp."--!,o / ptsd.n r^' vL - Uc/R- !.,r$mfl on \dneDe,snr'io" - rclfiA)wr,.i*,- r.,Yn+ r,.,, ., r .en m"ni.a..,sc - .- G,-

Ve9''

Pr*nt R6idmtiat AddEs of enDtovee it.aQah, 4ear t^6 CrftjtH zoaDcA Lt cDa 6na@|

r.(el (b) Pe@enr Raidentiat AddB of Emproyce :

tztt 1,.apo- rc^- . C"ri^s1A ,e

1.(0",ji;E;,.,-'T..1" f,,t:yr l aai (o!,-wo,Lhop d MU pesionar (.nbe",,." , at tn4ortror?Bc tttd.,Renmt ( ?nh. ob{;estry.

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:"1h:i:iil:JAif: ::fj']'"i,irv Bi'li -d,i.. r€,"phqe 8,,, / ad^, (irdlcvnbd r:rti.utm r"I (orj,*) 6),jqt- )r? lq3,

Tel(Reiden.e) oq4s^2?-- (w,$

'fD code)

a. s, LyF{ +q eA-oi l. oaa4ertl+oaa79

nibor io'nins pGenr,nshturon: 20- a7 )at"l.ini,,s Fpo{ at rhc Fecnt irerjtu,"

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Nane or vo negioiiiGEiieF-t hnhg \4as d6\e/ rf tflinils tuas dotu it,-tt e". 9* u" aai;u,t ,t,i.t ,i*ii

D^" a,'1 pta@ ori;;4

rs Aate rA.<a &o prcloe

3? l6D

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subjer ::'

z?1,Jf,

\dc. ror rPo I f!qudlr(rtor dod.nondl tugish.bm€rhkJbpdr.ut:Fpru,ruhcd and!trl|<t e r rer eoring ou I ktx.ha€r 6notJpp[.,btc.

2.(r) copyorDegrediticate. or "uo" -o ""

o"O*,nu"n o _"iy*o2.(t) copy of Resish,rion or Mrrs ."u rc a"g,*

"n*r,"u _ vf2uo

3 (a). Debib of rhe reachng up€rjence rill daie

o4c, rr92.t* .c,q,, 2":b 6

abLl

2

To be rill€d tn by Er Amy pssonnd only:

\d" ts?\e)o,' b@' {LrdeEd r-f\ uu N, reptrbon:."ny olJ)e hb tuuon/maJadt . ouryeaunnS La*rye( !,e. pt€s€ sivedebik.

B.ro€ joinins presnr i$riturion r w4 wq*rns d fl5 ,LAKts++6ee +b<"t7trcr{ 6}

^re odcoL.#d rei;cred;

6'3ruc / di!i6#:rH$ts*jr6 Serievjns ordd h encro*d fom rhe PEvious

Numberof Rgsfth pubt latioG I n

5 G) rnhm:hotu j.rmrs:

t ((l sbie/rNhtohon.tJournatsl

I have drawn bbt dotuments tom this .ollcSe jn rhe curPnt filncd year d under:

6. (. ) {copy of nr PAN & Fo.m 16 ODS .ertiri.,te) lor financiar y6r 2017-13 aF a6ched)

2.

L Dl 4!4rrrA { aslb-- o'r)!. --,,---- A3<,< 6^1 -o'<toa9- e.D \ t,rD14.,<'.d-

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otz91{TAtct fgive :n underbtng thi Lh

. lA" aor oFp1tsd m)n[ .o r\ orr' veJ..dt Co pB" tLtrtodon A d r.trLtry.R-,dc1r,nhe(u.'i id."detr,, r.r-ro, lnepu,p6eor v..d.c.mr1r.r a,n not lEving pdvate pncdce an wheE oR I am pacticinS at

Fudher Lnrre rhat I rm not do'ng inyPr&tice o. nor woiknS in any oLher hospital durinS conege hours.

compleE debik with regrd 60 work sp€ en.e hs b.rn pbvid€d & noLhing h6 tEn

r am not work'n3 in any other medical .ollege/dental .olege in rhe shb or oubidc th€ sbte,n.ny caF.iiy Resulaf / conbactuat /

^dhN _ Fu hme / pait hnc / Ho.ora,y.

lr is delared ihar ea.h shremenland/or conicnb o1 &h ddtmrjon and /or d(uadb,ertiti.dd Nbmided along witi dr decldahon forn, by rtre Ddeisicned aE abelublyrue mdRr ,nd auihenti. In L\e 4ent or bJr shrenent made in fiis d(taratio;lsrbequenuy iuining our b be in.orred or lalse ihe undersiSned h6 unde6led andacepbd th.t su.h nisddtdarion tn rslrt to,ny .ontent oI rhis d<laration shal aho be

T:*.{ 3 a crcs mhiondud rhepby €nde.ins ihe unde6igned liabre for nGsarydis.ipliiart actio. (including re'novat of hii name tmn Iidjan Medi.at Rcrgjsre4

SICNATURE OFTHE EMPTOYEE

ENDORSIMENT

l]' ..ll"l ..1,,',.qi, ,o, rrr hF.uda.3rJri..db.,!dr ndrJ hq4rf,,i,'., :.^'"- .rd.,,..itu.,"r\.o1tsr,. Lr.d-.t.,rondoendorA.h""boe":.I1.,11,'^.

,'"..r: d rhc <errific,E"/ do.umenbrhe o,is nrt lcd iri.devdocmrr, \ ,< subnin.d bv $erl rhc.oncp,ned t1\rjtoh :nd hrve found rhen r. bc

' ."10,od,,n.ldl1. Ad.n 4 J !9?/^ t a a.Jc n.i tDs\ms s !arryins od

rnJ o$eri.bvh dunng.o[e3p$o4i,3 ,ou6ie rrom -ijJ"i'*r,.r*"l]1.-j:'l:",. :. ",.1- a , i3 our tu h" .i,j prr or h.\rrr nr uNe, r3 ! d J,: I rls b,, o,,t \ .e po, . o. b.,o". rt " d- td,,1r I m-L h-ieh

,&Ayt- ,LcounieBigncd eiih danp by 0,e

DiKtor/Dcnn/Prn.ipar

n-.r r'^.p-r . - pr,ro o rr JE.pr,viEn"ii D."ilI'rinflDJIol rhe.o cqp

4',r, ?i;:i!lTl,'r*'xf rn*;E;;"-rr-c"'nr'"l -p,o urp'*-r +p .mor-iGirpiirc.p, .r .*p. | , \ d- c;J/ Er--;;,.fi1D-"G;i;iE/ airrhircnd / D€,i. iuohenthrs,rh.h.d *;prcoror

c.o "r

pi'+-r / vd., c;J/ ai;(ry uirt.J6G;;;ii

ldm8rep irthc.*.edNhucLopF{ or Grrcc!erh}i!ire\ of Bnsiid rc d,,qr.c.p,",,r r,.g^tnn","r rreFs;;dEi*copv or..po.

".."..*,r,.,rJr*,r r^-Eiq;;;;b;iEI elLj bcfore rou ri{ or6entr6tjtuFFeri{n8o.Js fnm rhe ere\ 08 ,;;hh;;f*,

" r 6 (rr.s *.hl,-ts) l.,t|; rJl;;.;ti;

t arsre."r r n --or re-r,crs *r,.irEri"cop, or ! c .{os-zcn b" ho r;htt;;;iir,;hd

copy ofPc. Bos zed leacher lerer lrom atfitiaiedunivgsin .(for P.c. Asssneni)

Sided bv the Tea.h€cP!!!-i

ztl 01l ,otS

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vt, ---e*"dn5jFc4 lvrlljroD. ""=--P!l!l

!9f!lTle D<ld.tion Flrn wi nor bp r.ep,ed rnd rhe pcaonwiltnor be rcunr€d s hache, if,nyortipabovedocumenh n rd en!toipd/rHa(hed with rhe Dedddrion FornTh. p?,!on hi rcr be mrnred r\ J ts:(her if rhe ongin,t of fhoio ID prcol, R€qisharionefrrQh_./ DegI* qifi.*F/ pAN cdd/ sl,re MednJ councit tD (,f ksu.dt-, e ndprodu.e rorvehh.rion.t rhe rjne of alesnenlall the reichds n$r subnir rhe revised delararion forn in this fornd onte tAnvdddanon forn slbniit€d in in otd format will mt be ,c.epted a"o r." *;I .ot u" i".i,oi