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 ...
Photograph
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
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.(i ) Date of joining present institution : ________________________ as ______________________
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2. Qualifications :
Qualification College & Univ. Year Registration No. of Name of the State
UG & PG with date Council
Under Graduate
Degree :
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.
2.(a ) Copies of Degree certificates of UG and PG degree to be attached.
2.(b ) Copies of Registration of UG and PG degree to be attached.
3. Details of the previous appointments/teaching experience:
Position Name of Institution From To Total
DD/MM/YY DD/MM/YY Experience in
years & months
Tutor/Demonstrator
Registrar/Sr.Resident
Assistant
Professor
Associate Professor
Professor
4 .(a ) Before joining present institution I was working at ________________________________ as
_____________________________________ and relieved on ______________________ after
resigning / retiring (Relieving order is enclosed from the previous institution).
4 .(b ) I am not working in any other college in the State or outside the State in any capacity
full-time / part-time.
5 . Number of Research publications in Journals during the last 3 (Three) academic years :
5 .(a ) International Journals: ___________________________
5 .(b ) National Journals: ___________________________
5 .(c ) State/Other Journals: ___________________________
6. Number of Research Projects on hand: ___________________________
7 .(a ) I am having PAN Card and my PAN is ____________________/ I am not having PAN Card.
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7 .(b ) I have drawn total emoluments from this college as under:-
Amount Received TDS
July, 2006
August, 2006
September, 2006
October, 2006
November, 2006
December, 2006
January, 2007
February, 2007
March, 2007
April, 2007
May, 2007
June, 2007
7 .(c ) (Copy of my PAN & Form 16 (TDS certificate) for financial year 2005-2006 are attached)
Declaration
1. I have not worked at any other college/institution or presented myself at any inspection
from October 2007 onwards till date.
2. It is declared that each statement and/or contents of this declaration and /or
documents, certificates submitted alongwith 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 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.
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. 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.
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.
Date: Place: Countersigned by the
Director/Dean/Principal
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Sl.No Documents Submitted
1.(c) Recent Passport size photo of the Employee, Signed by Dean / Yes No
Principal of the college.
1.(d) Photo ID proof issued by Govt. Authorities : Passport / Driving Yes No
Licence / PAN Card / Voter ID
1.(g) Copy of Passport /Voter Card / Ration Card / Electricity Bill / Yes No
Driving License Attached as a proof of residence.
2.(a) Copies of Degree certificates of UG and PG degree. Yes No
2.(b) Copies of Registration of UG and PG degree. Yes No
3. Copy of experience certificate for all teaching appointments held Yes No
before joining present institute.
4.(a) Relieving order from the previous institution. Yes No
7.(a) PAN Card Yes No
7.(c) Form 16 (TDS certificate) for financial year 2005-2006 Yes No
Signed by the Teacher : Countersigned by Dean / Signed by the Inspector :
Principal
Date : Date : Date :
NOTE :
1. 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.
2. The person will not be counted as a teachers if the original of Photo ID proof,
Registration Certificates / Degree certificates / PAN Card (if issued) are not
produced for verification at the time of inspection.
3. All the teachers must submit the revised declaration form in this format only.
(Any declaration form submitted in an old format will not be accepted and he will
not be counted as a teacher.)
