Registration Form 571b1e

KARNATAKA STATE PHARMACY COUNCIL No. 514/E, 1 Main, Vijayanagar Club Road, R.P.C. Layout, nd Vijayanagar 2 stage, Bangalore - 560 040 st Ph: 23404000, 23383142 Fax : 23202345 E-mail [email protected] : Web : www.kspcdic.com Timings: 10.00 a.m. - 1.00 p.m.

INSTRUCTIONS TO OBTAIN ED PHARMACIST CERTIFICATE 1,050/- in the form of K.S.P.C and The following documents have to be submitted along with a fee of Rs._______ 2,500/- in favour of K.R.P.W.T. Rs._______

1. D.Pharm / B.Pharm / M.Pharm / Certificate in original with A4 Size Xerox copy (each). 2. Marks Card of First and Final year D.Pharm / B.Pharm / M.Pharm in original with A4 Size xerox copy. 3. S.S.L.C. Marks Card / Transfer Certificate / Cumulative Record in original in of Date of Birth with one A4 Size Xerox Copy) 4. Recent port size colour photos (2 Nos.) with candidate signature on the back of the photos. Photographs to be identified by the Principal of your college or any Gazetted officer with seal and signature. 5. Blood Group report issued by a pathology laboratory / hospital. 6. Letter of PCI addressed to the principal regarding the approval stuatus of the college to conduct D.Pharm / B. Pharm / M. Pharm course for the ission year of the student.

Note: The Registrar reserves the right to call for any document/s to satisfy himself on the eligibility of the Applicant for registration.

Encl : 1. Form “G” - Scroll down 2. Declaration 3. Information Sheet

Karnataka State Pharmacy Council Vijayanagar, Bangalore 560 040

FORM G (See rule 48) APPLICATION FOR FRESH REGISTRATION OF PHARMACIST (Under the Pharmacy Act, 1948)

To, The Registrar, Karnataka State Pharmacy Council No. 514/E, 1St Main, Vijayanagar Club Road, R.P.C. Layout, Vijayanagar 2nd Stage, Bangalore 560 040.

Sir,

Siganature

1. I request that my name may be ed as a Pharmacist and that I may be issued the Registration Certificate Under the Pharmacy Act, 1948 of Registration. 2. Particulars requested are given on the reverse of this application. 3. I enclose herewith for your perusal and return the Certificate in their Original and their copies for record in your office. 4. I hereby declare that I have read carefully and understood the instructions and particulars supplied to me and that all entries on the reverse of this application and the information sheet are true to the best of my knowledge and belief. 5. I agree that I will follow the rules of the Pharmacy Council which may be laid down for the guidance of the ed Pharmacists from time to time. 6. I agree to produce the valid Identity Card on demand by the Inspector of Pharmacy Council / Drugs Inspector / any other officer authorized by the Government of Karnataka form time to time. 7. I agree to furnish any change in my address to the council. 8. I am enclosing a D.D.No. ........................Dated ........................ Of Rs................... In favour of “The Registrar, Karnataka State Pharmacy Council, Bangalore.

Your faithfully,

Place :----------------------------Date :-------------------------------

Signature: ------------------------------------------------------------(Name in Capital Letters) Specimen Signature of the Applicant

1.

2.

3.

1. Applicant's Name in full (In Capital's Letters) 2.

Father's Name (In Capital's Letters) Mother’s Name (In Capital's Letters) Husband’s Name (In Capital's Letters)

3. Place and Date of Birth (Proof of age to be attached)

Place : Date

Month

Year

Date of Birth: 4.

Nationality

5.

Current place of work with full address

6.

a. Current Residential Address in Karnataka State

......... ..............................................................................: ......... ..............................................................................: ......... ..............................................................................: Ph :.................................................Mob: ............................................ E-mail :..............................................................................................:

......... ..............................................................................: b. Permanent Address

......... ..............................................................................: ......... ..............................................................................: Ph :.................................................Mob: ............................................ E-mail :..............................................................................................:

7. Year of ing the Matriculation examination or an examination prescribed as being equivalent to Matriculation examination (kindly attach Original Certificate with A4 size Xerox Copy) 8. Qualification (Please attach Original Certificate with a A4 size Xerox copy) 9. Month and Year of ing the qualifying Pharmacy Examination. 10. Name of the Examining Body / University 11. Name of the institution where training was undergone (750 hrs for D.Pharm, 500 hrs for B.Pharm) as Per education regulation in force. 12. Name and address of the Institution from where the Qualification was secured

Date :-----------------------

Signature of the Applicant

KARNATAKA STATE PHARMACY COUNCIL (Constituted Under Pharmacy Act. 1948) No. 514/E, 1 Main, Vijayanagar Club Road, R.P.C. Layout, Vijayanagar 2 stage, Bangalore 560 040.

Information sheet to be submitted with Form G I. NAME OF THE PHARMACIST ( Mr. / Mrs. / Ms). II. REGISTRATION NO. III. FATHER'S / HUSBAND'S NAME

IV. RESIDENTIAL ADDRESS

Tel / Mob:

PIN CODE E-mail: V. DATE OF BIRTH

VI. BLOOD GROUP

DATE AGE

MONTH

YEAR M

SEX

YEARS

F

VII. OFFICIAL ADDRESS (PRESENT WORKING ADDRESS)

Tel / Mob:

PIN CODE E-mail: VIII. QUALIFICATION CODE 01. D.Pharm 04. Ph.D.,

CODE

02. B.Pharm 05. Qualified Person

XI. PLACE OF PRACTICE

03. M.Pharm 06. Other specilaity :--------URBAN

&

CODE 01.Chemists & Druggists 02.Teaching 03. istration 04. Hospital 05. Industry 06. None

RURAL

101. Private 102. State Govt. 103. Central Govt. 104. Public Sector 105. Industrial Estd.,

106. Corporation 107. Zillapzrishat 108. Unemployed 109. Any other profession, Specify .........................................

XII. OTHER DETAILS D. Pharm Certificate No.

Year of ing

B. Pharm Certificate No.

Year of ing

M. Pharm Certificate No.

Year of ing

Ph.D Certificate No.

Year of ing

Pharm.D Certificate No.

Year of ing

Name of the University Name or the Institution & Address

Note : USE CAPITAL LETTERS

USE

MARK WHEREVER REQUIRED

DECLARATION TO BE SUBMITTED ALONG WITH THE APPLICATION FOR REGISTRATION

I.

I ................................... hereby declare that I have not ed my name in any other State Pharmacy Council in India. This is my first application made with required enclosures for registration in this state after obtaining a Diploma / Degree in Pharmacy.

II.

I hereby declare that prior to this application, I had ed my name in State Pharmacy Councils detailed below.

Registration

Name of the Pharmacy Council

Registration No. And Date

Duration From

Qualification To

Ist registration

Ist Re- Registration

nd

2 Re- Registration

III.

I hereby declare that I desire to practice profession of pharmacy in the State of Karnataka by residing in this State .

IV.

I hereby declare that the above information is true and correct to the best of my knowledge and belief.

V. I understand that my application is liable to be rejected summarily or the registration is liable to be cancelled forthwith, if the above information is proved to be false in any state before or after the issue of registration in addition to disciplinary proceedings and legal action.

Date : --------------------

Signature of the Applicant

KARNATAKA ED PHARMACISTS WELLFARE TRUST RULES AND CONDITIONS FOR ENROLLMENT IN THE TRUST 1. Candidate must be a ed Pharmacists who has paid Life Team Registration in Karnataka state Pharmacy Council. 2. Benefit under scheme will be given only if he is in the rolls of the Karnataka state Pharmacy Council at the time of the claim. 3. At the time of Enrollment the age should not exceed 60 years. 4. The quantum of amount to be given in case of death shall be a minimum amount of Rs.75,000/- which will be reviewed every year depending trust resources. 5. A partial disbursement up to 1/3 of the minimum amount for the medical treatment in case of serious illness such as cancer, cardiac surgery, kidney transplantation etc. to be decided by Trust Executive Committee on Merits. Such partial amounts paid will be deducted from final settlement to the nominee. RULES FOR CLAIMS : 1. In case of Death : Death Certificate issued by a competent authority in original shall be produced along with claim. 2. The claim shall be made in writing by the nominee whose is ed in the trust. 3. In case the ed nominee is not alive at the time of claim, only the legal heir approved by the court of law Can make the claim producing the proof of their legal heir rights. The clam should be made with in 3 months (or 90 days) from the date of death. IN CASE OF MEDICAL CLAIM : A discharge certificate from the Hospital / Nursing Home indicate the brief report of illness and the treatment given should be produced in original or a certified copy.

KARNATAKA ED PHARMACISTS WELFARE TRUSTY (Reg.) Vijayanagar, BANGALORE - 560 040)

APPLICATION FORM (Fill in block letters only)

1. NAME OF THE APPLICANT (As appears in the registration certificate)

:

2. REGISTRATION NUMBER (copy of the certificate to be attached)

:

3. FATHER’S / HUSBAND'S NAME

:

4. SEX

:

5. AGE / DATE OF BIRTH

:

MALE

FEMALE

/

D 6. MARTIAL STATUS

:

8. ADDRESS (permanent)

:

Preferred Mailing Address

9. NAME OF THE NOMINEE

MARRIED / SINGLE

D

M

M

Y

7. BLOOD GROUP

Y

Y

Y

Y

Y

Y

:

:

:

(Recent port size colour photos (2 Nos.))

: Specimen signature of the Nominee : 1.

Affix photo of the nominee

2.

3.

10. AGE & DATE OF BIRTH OF THE

:

NOMINEE

Yrs D

D

M

M

Y

11. RELATIONSHIP TO THE APPLICANT

:

12. IN CASE OF MINOR, PLEASE MENTION GUARDIAN’S NAME

:

13. ADDRESS OF THE NOMINEE

:

13. MODE OF PAYMENT

: DD / PAY ORDER NO. ..................................................................................... BANK: . .................................................................. PLACE: .........................

Note : DD to be sent in favour of Karnataka ed Pharmacist Welfare Trust, payable at Bangalore -----------------------------------------------------------------------------------------------------------------------------------------------------------I, the undersigned solemnly confirm that the above particulars are true to the best of my knowledge and belief. Further, I declare that I Shall abide by the rules and regulations laid by the Trust from time to time. DATE :

Signature of Applicant

-----------.---------------------------------------------------------------------------------------------------------------------------------------For office use only Verification remark by office: Enrollment No. : MANAGING TRUSTEE