DECLARATION FORM

2 0 1 1 - 1 2
FACULTY

1 Name of Institution* K A 3 4 0 2
2 Name V I K R MA SM
3 Date of birth 0 3 1 1 1 9 7 9 Med Reg Council K M C
Med Reg Coun Number 6 9 0 7 4
4 Photo ID Issued by* PAN/Passport/MCI/Driving License/Voter ID/State Med Coun No. Passport size photo
countersigned by
(blacken)
the Dean/Principal
5 Number B Y X P S 4 1 2 1 C
6 Designation*(Tick) Tutor SR Asst. Prof. 3 Assoc. Prof. Prof.
7 Department*
8 Category (Tick) GEN SC ST OBC PH Ex Serviceman
9 Residential Address H N 5 4 B C R O S S M A D I W A L A
City B A N G A L O R E State* K A Pin 5 6 0 0 6 8
10 Permanent Address 6 7 0 2 _ 4 B N E A R V T G H S
City G A D A G State* K A Pin 5 8 2 1 0 1
11 Telephone (O)
12 Telephone (R )
13 Mobile 9 7 3 1 9 8 1 6 6 5
14 Email d o c _ v i k r a m @ y a h o o . C o m
15 DOJ of present inst. 0 1 0 8 2 0 0 8
Date of qualifying Degree* State* University/Institute*
16 Primary Qualfcn. 3 0 0 4 2 0 0 M B B S
3 K A K A 1 4 0 2
17 a) Post Grad. Diploma d d m m y y y y 1 2 3 4 5 1 2
17 b) Post Grad. Degree 3 0 0 4 2 0 0 8 M D A N S K A K A 3 5 0 2
18 Superspeciality d d m m y y y y 1 2 3 4 5 1 2
19 MCI-MeT Course Basic (Yes/No) Advanced (Yes/No)
(Previous Appointments) Institute* Joining Date Relieving Date
20 Tutor 1/ JR 1 d d m m y y y y d d m m y y y y
21 Tutor 2/ JR 2 d d m m y y y y d d m m y y y y
22 Senior Resident 1 K A 3 4 0 2 0 1 0 8 2 0 0 8 1 4 0 6 2 0 0 9
23 Senior Resident 2 d d m m y y y y d d m m y y y y
24 Senior Resident 3 d d m m y y y y d d m m y y y y
25 Assistant Professor 1 K A 3 4 0 2 1 5 0 6 2 0 0 9 d d m m y y y y
26 Assistant Professor 2 d d m m y y y y d d m m y y y y
27 Assistant Professor 3 d d m m y y y y d d m m y y y y
28 Associate Professor 1 d d m m y y y y d d m m y y y y
29 Associate Professor 2 d d m m y y y y d d m m y y y y
30 Associate Professor 3 d d m m y y y y d d m m y y y y
31 Professor 1 d d m m y y y y d d m m y y y y
32 Professor 2 d d m m y y y y d d m m y y y y
33 Professor 3 d d m m y y y y d d m m y y y y

34 Declaration Of Faculty
i. I, Dr.______________________________of the Department of ________________________at ________________________

___________________________do hereby give an undertaking that I am continuously working as a full time teacher at the institute.
ii. I am not practicing anywhere or carrying out any other activity OR I am practicing at ____________________________
in the city of ___________________ and my hours of practice are __________________________________.
iii.
It is declared that each statement and/or contents of this 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 is
liable for necessary disciplinary action (including removal of my name from Indian Medical Register).
iv. I am having PAN Card and my PAN card number is _____________________________/ I am not having PAN Card.
Date:
Place: SIGNATURE OF THE FACULTY
35 Endorsement by Head Of Institution

This endorsement is the certification that the undersigned has satisfied himself/ herself about the correctness and veracity of each
content of this declaration. I have verified the certificates/ documents submitted by the candidate to the institute.

Date: Place: Countersigned by the Director/Dean/Principal

Date of Assessment: Signature of the Assessors: