Teaching Staff for Medical Course
(Use separate sheet for each specialty / Department and to be signed by the Principal / Dean)
Name of the College:
Name of the faculty Experience Phone No. E-mail ID
Principal
Medical
Superintendent
Specialty Name of the faculty Experience Phone No. E-mail ID Unit
Department of Anatomy
Professor
Associate Professor
Asst. Professor
Tutor / Demonstrators
Department of Physiology
Professor
Associate Professor
Asst. Professor
Tutor / Demonstrators
Department of Biochemistry
Professor
Associate Professor
Asst. Professor
Tutor / Demonstrators
Department of Pathology
Professor
Associate Professor
Specialty Name of the faculty Experience Phone No. E-mail ID Unit
Asst. Professor
Tutor / Demonstrators
Department of Microbiology
Professor
Associate Professor
Asst. Professor
Tutor / Demonstrators
Department of Pharmacology
Professor
Associate Professor
Asst. Professor
Tutor / Demonstrators
Department of Forensic
Medicine
Professor
Associate Professor
Asst. Professor
Tutor / Demonstrators
Department of SPM
Professor
Associate Professor
Asst. Professor
Epidemiologist- Cum /Asst.
Professor
Statistician - Cum /Asst.
Professor
Tutor / Demonstrators
Specialty Name of the faculty Experience Phone No. E-mail ID Unit
Medical Officer Health Cum
Lecture / Asst. Professor Rural
Training
Lady Medical Officer
Medical Officer Health Cum
Lecture / Asst. Professor Urban
Training
Lady Medical Officer
Department of General
Medicine
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Department of TB & RD
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Department of DVL
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Specialty Name of the faculty Experience Phone No. E-mail ID Unit
Department of Psychiatry
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Department of Pediatrics
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Department of General Surgery
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Department of Orthopedics
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Specialty Name of the faculty Experience Phone No. E-mail ID Unit
Department of ENT
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Department of Ophthalmology
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Department of OBG
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Jr. Resident
Antenata Medical Officer Cum –
Lecturer / Asso. Professor
Maternity & Child welfare
Officer Cum – Lecturer / Asso.
Professor
Department of Radio diagnosis
Professor
Associate Professor
Asst. Professor
Tutor / Registrars
Specialty Name of the faculty Experience Phone No. E-mail ID Unit
Department of Radio therapy
(Optional)
Professor
Associate Professor
Asst. Professor
Tutor / Registrars
Department of Anesthesiology
Professor
Associate Professor
Asst. Professor
Tutor / Registrars / Sr. Resident
Department of Physical
Medicine & Rehabilitation
(Optional)
Professor
Associate Professor
Asst. Professor
Sr. Resident
House Surgeon / Jr. Resident
Department of Dentistry
Professor
Associate Professor
Asst. Professor
Tutor / Registrar
Signature of the Principal
Teaching Staff for Dental Course
Name of the College:
Name of the faculty Experience Phone No. E-mail ID
Principal
Specialty Name of the faculty Experience Phone No. E-mail ID
Prosthodontics, Crown Bridge, Aesthetic Dentistry and Oral Implant logy
Professor
Associate Professor
Asst. Professor
Oral Pathology, Microbiology & Forensic Odontology
Professor
Associate Professor
Asst. Professor
Conservative, Endodontics & Aesthetic Dentistry
Professor
Associate Professor
Asst. Professor
Oral & Maxillofacial Surgery and Oral Implantology
Professor
Associate Professor
Asst. Professor
Periodontology & Oral Implantology
Professor
Associate Professor
Asst. Professor
Orthodontics & Dento-facial Orthopedics
Professor
Associate Professor
Asst. Professor
Specialty Name of the faculty Experience Phone No. E-mail ID
Pedodontics & Preventive Dentistry
Professor
Associate Professor
Asst. Professor
Oral Medicine & Radiology
Professor
Associate Professor
Asst. Professor
Public Health Dentistry & Preventive Dentistry
Professor
Associate Professor
Asst. Professor
Dental Materials
Professor
Associate Professor
Asst. Professor
Dental Anatomy/Oral Biology
Professor
Associate Professor
Asst. Professor
Signature of the Principal
MEDICAL TEACHING STAFF IN DENTAL COLLEGES
Specialty Name of the faculty Experience Phone No. E-mail ID
Anatomy
Professor
Associate Professor
Asst. Professor
Physiology
Professor
Associate Professor
Asst. Professor
Biochemistry
Professor
Associate Professor
Asst. Professor
Pharmacology
Professor
Associate Professor
Asst. Professor
General pathology
Professor
Associate Professor
Asst. Professor
Microbiology
Professor
Associate Professor
Asst. Professor
General Medicine
Professor
Associate Professor
Specialty Name of the faculty Experience Phone No. E-mail ID
Asst. Professor
General Surgery
Professor
Associate Professor
Asst. Professor
Anesthesia
Professor
Associate Professor
Asst. Professor
Signature of the Principal
FACULTY IDENTIFICATION FORM
1. Name of the faculty
2. Council Registration No.
(if applicable)
3. Designation
4. Department
5. College
6. City
7. Date of Birth
8. Residential Address
9. Telephone No. Residence:
With STD Code Office:
Mobile:
10. E-Mail address
11. Nature of appointment
Tick (√ ) appropriate [ Permanent/ Temporary/ Adhoc/ Honorary/ Part Time]
12. Date of joining
13. Aadhar Card No:
( Enclose copy)
14. In case of not having Aadhar Card
enclose any one photo ID Tick (√ ) [ Passport Copy/ Driving License/ Pan Card/ Voter ID]
appropriate ( Enclose copy)
15. Employee Photo Employee’s Thumbprint Employee Signature
Dean/ Principal’s Signature
15. Qualifications:
Registration No. of UG
College & Name of the
Qualification Year & PG with date (if
University Council
applicable)
DEGREE
POST
GRADUATION
HIGHER
SPECIALITY (if
any)
16. Details of Teaching Experience:
Name of the From To Total experience in
Designation Department
Institution DD/MM/YY DD/MM/YY Years & Months
Before joining present institution I was working at ____________________________ as
________________________________________ and relieved on ___________ after resigning/ retiring.
I am having PAN Card and my PAN is __________________________ / I am not having PAN Card.
DECLARATION
It 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 absolutely true,
correct and authentic. 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 miss
declaration 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 (including
making the individual ineligible for any University activity)
Faculty:
Signature: Date: Place:
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 endorse the above
mentioned declaration as true and correct. 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.
Date: Place: Countersigned by the Director/ Dean/ Principal
Directives to fill this form:
1. All the teachers must submit the application in this format only.
2. Please attach photo ID/ PAN Card/ Pass Port Copy/ Electricity Bill/ Driving License/
Voters Card as proof of residence and ID Proof with the Form.
3. Please fill the form in block letters using black ink only.
4. Information must be in legible hand writing.
5. Only left thumb impression is to be marked with in the box provided.
6. Please affix Passport Photo Graph of the size as given in the Form.
7. Please sign only within the boxes provided.
8. Enclose copies of all the relevant Certificates/ Orders.
