Application for Registration, ,

,
Under section 33 of Pharmacy Act (V[I of 1948)
TheRegistrar,
RAJASTHAN PHARMACY COTINCIL
Govt. Dispensary Campus, SardarPatel Marg,
JAIPUR=30200 l, Tel.lF ax : 0l 4l -2228600
Sir,
I request that my name be entered in the REGISTER OF PHARMACISTS maintained by the RAJASTHAN
PHARMACYCOLTNCIL, undersection32ofthePharmacyAcll948 (VIII of 1948), andthaton such entryl maybe
furnished with a certifi cate of registration.
I have given the particulars required on the reverse, and I declare that they are correct, and that I reside/carry on
the businessorprofession ofPharmacy inthe StateofRajasthan, myaddress beingas given below.
The Prescribed Application fee of .Rs. 1000/- one thousand only is paid herewith vide I.P.O./D.D./Banker
Council.Jaiour'
The undermentioned diplomas/certificates/documents are enclosed in original with one attested Photocopy
and itis requestedthatthey be returnedto meonthe disposalofthe case.
'
I.sbcoNpeRYSCHooLCERIIFICATE (tutarksheuisnotacceptable)
2. SENIOR SECONDARY CEMIFICATE/ Mark Sheet
3.DEGREE/DIPLOMA/PROVISIONAL CritiJi*trituedbyUniversity/Boardasaproofofhavingpassed
approved examination ofPhannacy. (Provisional Certificate issued by college is not acceptable)
4. MARK SHEET ofDegree/Diploma Pharmacy.
5. PRACTICALTRAINING completiontorm in case otD.Phmma Candidates only.
6. CERIIFICATE OF REGISTRATION as aPharmacist issued by other State Pharmacy Counc il (with two
attestedphotocopies)
7 .
ilfuo
lotest possport siw PHOTO with name and datu prtnted on it one photo to be affaed on application
lorm.
8. AFFIDAVIT in support ofdocuments and other details.
9. Latest proofofresiding/carrying on profession or business ofpharmacy in Rajasthan. (Election Photo ID
Catd, Pasqnrt, Driving Licence, Ration Cord etc.)
Bonside resident urtlyiru, t no, admitted as a proof of resident
10. I undertake to inform the Registrar, Rajasthan Pharmacy Council, my professional address immediately
aftertakingup employment (as aregisteredpharmacist/competentperson on any druglicence oranyother
To
Yours faithfully
FullName:.....................................
Note : Signature should be same as on
pract. Training form & Midavit
Address:
PARTICULARS TO BE ruRNISHID BYTHEAPPTICANT
Name (in block letters)
Residential Address....
Qualification
for registration (i) D.Pharma / B.Pharma
(ii) Registered Pharmacist with...... ..."...state Pharmacy Council.
[Year
of Passing the D.Pharnra/B.Pharnra with the name of Board/
University or other examination body from which passedl
Employment, if any, Name of the Employer..
Note :It is futy of every Registered Pharmaxist to infonn the Registrar, Rajasthan Pharmacy Council
his/hcr professional address immediately after taking up employnent (as a registered plwnnacist
lCompetent person on any drug licence or any other employment and he/she should also lceep on
intorming every change in his/her professional address/employnentlResidential Address.
(Applicant Signoture)
Full Name.
Address......
Dated."
Pin...
Ploce
Pin