PHARMACY COUNCIL OF INDIA STAFF DECLARATION FORM From Teacher's Name ...... K.G. Balasubramaniam ..................... . (as on University Degree certificate) Recent Passport size photo of the Employee Signed by Dean/Principal of the College. Date of Birth & Age ...... 18.06.1988 & 29 ............................ . Qualification I B.Pharm College & University Madurai Medical College & Dr.MGR Medical University Year 2009 Registration No. with State Pharmacy Name ofthe State Pharmacy Council M.Pharm Madurai Medical College & Dr.MGR Medical University 2015 16437 Al Tamil Nadu State Pharmacy Council ..-. I (Ph.D.)/others J Copies of Registration Certificate and University degreeIPGlPh.D. be attached. Present Designation : _________________ _________________ ____ College: Dhanalakshmi Srinivasan College of Pharmacy City: ___________________________ Nature of appointment : Whether belongs to: O.G.lSC/ST/OBC/&-servicelOthers Contd. on page 2
Transcript
PHARMACY COUNCIL OF INDIA
STAFF DECLARATION FORM
From
Teachers Name KG Balasubramaniam (as on University Degree certificate)
Recent Passport size photo of the Employee Signed by DeanPrincipal ofthe College
Date of Birth amp Age 18061988 amp 29
Qualification I
BPharm
College amp University
Madurai Medical College
amp DrMGR Medical
University
Year
2009
Registration No with State Pharmacy
Name ofthe State Pharmacy Council
MPharm
Madurai Medical College
amp DrMGR Medical
University
2015
16437 Al Tamil Nadu State Pharmacy Council
----~---
I (PhD)others J Copies of Registration Certificate and University degreeIPGlPhD be attached
Present Designation 2~~~~~~_________________
Department~~~~~~_________________~____~_
College Dhanalakshmi Srinivasan College of Pharmacy
City --~--==___________________________
Nature of appointment Permanent~oraryAdhoelHooorarylPart-tfme
Whether belongs to OGlSCSTOBCamp-servicelOthers
Contd on page 2
2
Permanent Residential Address of employee ~~~~~l RtTQctt_ ~~~~__
Klt2lt2 va A( I tte(lA~ LbJla) fh ~iur (W___
_~ E1JtbJL -Dc ( 36 SULshy
Copy of PassportVoter CardRation CardPAN NolElectricity BillIDriving License Attached as a proof of residence
STD Code Phone No
lt1cgt zIi LashyPhone amp Fax Number ~e ________________~~~~~~~~________ with Code
Residence ------ shy
E-mail addressgmbalu88gmailcom
Date ofjoining present institution -OSO6--2=O1-7_____________as Assistant Professor (Designation)
Details of the previous appointmentsteaching experience
From ToPosition Name of Institution Total Experience in years
Lecturer
Reader Assistant Professor
- ----~-
Professor
Principal
1) Before joining present institution I was working as and relieved on _______ after resigningretiring (relieving order is enclosed from the previous institutioll)~
2) I hereby undertake that I have not given my name as teaching faculty in any other Pharmacy institution for teaching any Pharmacy course and not working in any where
other than this institution Pharmacy CollegeMedical CollegelDental CollegeIndustryCommunity PharmacyHospital PhannacyGovt Serviceany other service in the State or outside the State in any capacity full-timepart-time other than the above
Contd on page 3
I
3
3) I have drawn total emoluments from this college as under (Please fill the data of last academic session) shy
April 20 May 20 June 20
-shy
Amount Received TDS I
July 20 August 20 September 20 October 20
I
bull November 20 i December 20 January 20 February 20 March 20
(Copy of my form 16 (TDS certificate) for the last financial year is attached)
Circle ____________
Declaration
1 I have not worked at any other pharmacy collegeinstitution or presented myself at any inspection during my employment in this college
2 It is declared that each statement andor contents of this declaration made by the undersigned are absolutely true and correct 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 (including removal of his name from Register ofRegistered Pharmacists)
Signature of the Employee
Date Place
Endorsement
This endorsement is the certification that the undersigned has satisfied himselfherself about the correctness and veracity of each content of this declaration and endorses the abovementioned declaration as true and correct 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 himselfherself for any such misdeclaration or misstatement
Co n erst DirectorDean ~pal in respect of Teaching Staff
Date Place
DHANALAKAHMI SRINIVASAN COLLEGE OF PHARMACY
- 621 212Thuraiyur Road Perambalur
02062017
APPOINTMENT ORDE~
To
KG Balasu bramaniam
Andavar Kovil Street Keelavani
Anthiyur taluk
Erode
Tamil NaduPin-63 8502
With references to your resume and based on the interview conducted by the
selection committee of Dhanalakshmi Srinivasan Charitable and Educational Trust
you are selected as a Assistant Professor in Olif Proposed Dhanalakshmi
Srinivasan College of Pharmacy Perambalur
Kindly send your willingness to accept the appointment along with 2
photographs and photocopies along with your Original certificates Relieving order
and Experience certificate
You should obey all the rules and regulations of our College of Pharmacy as
per the discussion
JOINING LETTER
From
KG Balasubramaniam
Andavar Kovil Street Keelavani
Anthiyur taluk
Erode
Tamil NaduPin-638502
To
The Principal
Dhanalakshmi Srinivasan College of Pharmacy
Perambalui - 621212
Respected Sir
Subject KGBalasubramaniam Joining as Assistant Professor on 05062017 - reg
With reference to the appointment order I am Joining duty as your institution as
Principal in the Dhanalakshmi Srinivasan College of Pharmacy in the FN of 05062017
Herewith I am submitting my original certificates ID proof and two photographs as per your
instruction for verification I will abide by the rules and regulations of the trust and College
(soniof1tk~Gal)esan ) whose date ofbirth is 18tbJun~ 1988 (NineteelllEighty Eight)
has been duly registered as amiddot
and is entitled to all the privileges granted under
The Pharmacy Act 1948 (Central Act No VIII of 1948)
as amended to regulate the practice of Pharmacy in the Stata of Tamilnadu
IN WITNESS Whereof are herewith affixed the $eal of the
Taniil Nadu Pharmacy COllncil and tha Signature of the
Registrar of the said Pharmacy Council
Note -(i) This Certificate shall remain in fCircetillgt~(illi Ffoibroary2021 days ofgrace uptoHhh May 20U T-fijS Certificate is issuoo afresh on l8022016
IL HE I
FORMshy( See Rule 79 (2) )
Registration ofAdditional QualifiICation (Under Section 35 of The Pharmacy Act 1948)
(he addItional 0(j)~jloma cerljicate c8Jegree a-ppearinsect below hers JJef1 inserl(~i in the C~~tfjter 0 ~hJJ111aciss_for the 1cfJ1tIi ~adll Q9)late t~tftA7j1J1 the ntD11e Sl the flCJ]f7Iflsect Cri(egi5tered 92harmaCis
Permanent Residential Address of employee ~~~~~l RtTQctt_ ~~~~__
Klt2lt2 va A( I tte(lA~ LbJla) fh ~iur (W___
_~ E1JtbJL -Dc ( 36 SULshy
Copy of PassportVoter CardRation CardPAN NolElectricity BillIDriving License Attached as a proof of residence
STD Code Phone No
lt1cgt zIi LashyPhone amp Fax Number ~e ________________~~~~~~~~________ with Code
Residence ------ shy
E-mail addressgmbalu88gmailcom
Date ofjoining present institution -OSO6--2=O1-7_____________as Assistant Professor (Designation)
Details of the previous appointmentsteaching experience
From ToPosition Name of Institution Total Experience in years
Lecturer
Reader Assistant Professor
- ----~-
Professor
Principal
1) Before joining present institution I was working as and relieved on _______ after resigningretiring (relieving order is enclosed from the previous institutioll)~
2) I hereby undertake that I have not given my name as teaching faculty in any other Pharmacy institution for teaching any Pharmacy course and not working in any where
other than this institution Pharmacy CollegeMedical CollegelDental CollegeIndustryCommunity PharmacyHospital PhannacyGovt Serviceany other service in the State or outside the State in any capacity full-timepart-time other than the above
Contd on page 3
I
3
3) I have drawn total emoluments from this college as under (Please fill the data of last academic session) shy
April 20 May 20 June 20
-shy
Amount Received TDS I
July 20 August 20 September 20 October 20
I
bull November 20 i December 20 January 20 February 20 March 20
(Copy of my form 16 (TDS certificate) for the last financial year is attached)
Circle ____________
Declaration
1 I have not worked at any other pharmacy collegeinstitution or presented myself at any inspection during my employment in this college
2 It is declared that each statement andor contents of this declaration made by the undersigned are absolutely true and correct 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 (including removal of his name from Register ofRegistered Pharmacists)
Signature of the Employee
Date Place
Endorsement
This endorsement is the certification that the undersigned has satisfied himselfherself about the correctness and veracity of each content of this declaration and endorses the abovementioned declaration as true and correct 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 himselfherself for any such misdeclaration or misstatement
Co n erst DirectorDean ~pal in respect of Teaching Staff
Date Place
DHANALAKAHMI SRINIVASAN COLLEGE OF PHARMACY
- 621 212Thuraiyur Road Perambalur
02062017
APPOINTMENT ORDE~
To
KG Balasu bramaniam
Andavar Kovil Street Keelavani
Anthiyur taluk
Erode
Tamil NaduPin-63 8502
With references to your resume and based on the interview conducted by the
selection committee of Dhanalakshmi Srinivasan Charitable and Educational Trust
you are selected as a Assistant Professor in Olif Proposed Dhanalakshmi
Srinivasan College of Pharmacy Perambalur
Kindly send your willingness to accept the appointment along with 2
photographs and photocopies along with your Original certificates Relieving order
and Experience certificate
You should obey all the rules and regulations of our College of Pharmacy as
per the discussion
JOINING LETTER
From
KG Balasubramaniam
Andavar Kovil Street Keelavani
Anthiyur taluk
Erode
Tamil NaduPin-638502
To
The Principal
Dhanalakshmi Srinivasan College of Pharmacy
Perambalui - 621212
Respected Sir
Subject KGBalasubramaniam Joining as Assistant Professor on 05062017 - reg
With reference to the appointment order I am Joining duty as your institution as
Principal in the Dhanalakshmi Srinivasan College of Pharmacy in the FN of 05062017
Herewith I am submitting my original certificates ID proof and two photographs as per your
instruction for verification I will abide by the rules and regulations of the trust and College
(soniof1tk~Gal)esan ) whose date ofbirth is 18tbJun~ 1988 (NineteelllEighty Eight)
has been duly registered as amiddot
and is entitled to all the privileges granted under
The Pharmacy Act 1948 (Central Act No VIII of 1948)
as amended to regulate the practice of Pharmacy in the Stata of Tamilnadu
IN WITNESS Whereof are herewith affixed the $eal of the
Taniil Nadu Pharmacy COllncil and tha Signature of the
Registrar of the said Pharmacy Council
Note -(i) This Certificate shall remain in fCircetillgt~(illi Ffoibroary2021 days ofgrace uptoHhh May 20U T-fijS Certificate is issuoo afresh on l8022016
IL HE I
FORMshy( See Rule 79 (2) )
Registration ofAdditional QualifiICation (Under Section 35 of The Pharmacy Act 1948)
(he addItional 0(j)~jloma cerljicate c8Jegree a-ppearinsect below hers JJef1 inserl(~i in the C~~tfjter 0 ~hJJ111aciss_for the 1cfJ1tIi ~adll Q9)late t~tftA7j1J1 the ntD11e Sl the flCJ]f7Iflsect Cri(egi5tered 92harmaCis
3) I have drawn total emoluments from this college as under (Please fill the data of last academic session) shy
April 20 May 20 June 20
-shy
Amount Received TDS I
July 20 August 20 September 20 October 20
I
bull November 20 i December 20 January 20 February 20 March 20
(Copy of my form 16 (TDS certificate) for the last financial year is attached)
Circle ____________
Declaration
1 I have not worked at any other pharmacy collegeinstitution or presented myself at any inspection during my employment in this college
2 It is declared that each statement andor contents of this declaration made by the undersigned are absolutely true and correct 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 (including removal of his name from Register ofRegistered Pharmacists)
Signature of the Employee
Date Place
Endorsement
This endorsement is the certification that the undersigned has satisfied himselfherself about the correctness and veracity of each content of this declaration and endorses the abovementioned declaration as true and correct 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 himselfherself for any such misdeclaration or misstatement
Co n erst DirectorDean ~pal in respect of Teaching Staff
Date Place
DHANALAKAHMI SRINIVASAN COLLEGE OF PHARMACY
- 621 212Thuraiyur Road Perambalur
02062017
APPOINTMENT ORDE~
To
KG Balasu bramaniam
Andavar Kovil Street Keelavani
Anthiyur taluk
Erode
Tamil NaduPin-63 8502
With references to your resume and based on the interview conducted by the
selection committee of Dhanalakshmi Srinivasan Charitable and Educational Trust
you are selected as a Assistant Professor in Olif Proposed Dhanalakshmi
Srinivasan College of Pharmacy Perambalur
Kindly send your willingness to accept the appointment along with 2
photographs and photocopies along with your Original certificates Relieving order
and Experience certificate
You should obey all the rules and regulations of our College of Pharmacy as
per the discussion
JOINING LETTER
From
KG Balasubramaniam
Andavar Kovil Street Keelavani
Anthiyur taluk
Erode
Tamil NaduPin-638502
To
The Principal
Dhanalakshmi Srinivasan College of Pharmacy
Perambalui - 621212
Respected Sir
Subject KGBalasubramaniam Joining as Assistant Professor on 05062017 - reg
With reference to the appointment order I am Joining duty as your institution as
Principal in the Dhanalakshmi Srinivasan College of Pharmacy in the FN of 05062017
Herewith I am submitting my original certificates ID proof and two photographs as per your
instruction for verification I will abide by the rules and regulations of the trust and College
(soniof1tk~Gal)esan ) whose date ofbirth is 18tbJun~ 1988 (NineteelllEighty Eight)
has been duly registered as amiddot
and is entitled to all the privileges granted under
The Pharmacy Act 1948 (Central Act No VIII of 1948)
as amended to regulate the practice of Pharmacy in the Stata of Tamilnadu
IN WITNESS Whereof are herewith affixed the $eal of the
Taniil Nadu Pharmacy COllncil and tha Signature of the
Registrar of the said Pharmacy Council
Note -(i) This Certificate shall remain in fCircetillgt~(illi Ffoibroary2021 days ofgrace uptoHhh May 20U T-fijS Certificate is issuoo afresh on l8022016
IL HE I
FORMshy( See Rule 79 (2) )
Registration ofAdditional QualifiICation (Under Section 35 of The Pharmacy Act 1948)
(he addItional 0(j)~jloma cerljicate c8Jegree a-ppearinsect below hers JJef1 inserl(~i in the C~~tfjter 0 ~hJJ111aciss_for the 1cfJ1tIi ~adll Q9)late t~tftA7j1J1 the ntD11e Sl the flCJ]f7Iflsect Cri(egi5tered 92harmaCis
(soniof1tk~Gal)esan ) whose date ofbirth is 18tbJun~ 1988 (NineteelllEighty Eight)
has been duly registered as amiddot
and is entitled to all the privileges granted under
The Pharmacy Act 1948 (Central Act No VIII of 1948)
as amended to regulate the practice of Pharmacy in the Stata of Tamilnadu
IN WITNESS Whereof are herewith affixed the $eal of the
Taniil Nadu Pharmacy COllncil and tha Signature of the
Registrar of the said Pharmacy Council
Note -(i) This Certificate shall remain in fCircetillgt~(illi Ffoibroary2021 days ofgrace uptoHhh May 20U T-fijS Certificate is issuoo afresh on l8022016
IL HE I
FORMshy( See Rule 79 (2) )
Registration ofAdditional QualifiICation (Under Section 35 of The Pharmacy Act 1948)
(he addItional 0(j)~jloma cerljicate c8Jegree a-ppearinsect below hers JJef1 inserl(~i in the C~~tfjter 0 ~hJJ111aciss_for the 1cfJ1tIi ~adll Q9)late t~tftA7j1J1 the ntD11e Sl the flCJ]f7Iflsect Cri(egi5tered 92harmaCis
(soniof1tk~Gal)esan ) whose date ofbirth is 18tbJun~ 1988 (NineteelllEighty Eight)
has been duly registered as amiddot
and is entitled to all the privileges granted under
The Pharmacy Act 1948 (Central Act No VIII of 1948)
as amended to regulate the practice of Pharmacy in the Stata of Tamilnadu
IN WITNESS Whereof are herewith affixed the $eal of the
Taniil Nadu Pharmacy COllncil and tha Signature of the
Registrar of the said Pharmacy Council
Note -(i) This Certificate shall remain in fCircetillgt~(illi Ffoibroary2021 days ofgrace uptoHhh May 20U T-fijS Certificate is issuoo afresh on l8022016
IL HE I
FORMshy( See Rule 79 (2) )
Registration ofAdditional QualifiICation (Under Section 35 of The Pharmacy Act 1948)
(he addItional 0(j)~jloma cerljicate c8Jegree a-ppearinsect below hers JJef1 inserl(~i in the C~~tfjter 0 ~hJJ111aciss_for the 1cfJ1tIi ~adll Q9)late t~tftA7j1J1 the ntD11e Sl the flCJ]f7Iflsect Cri(egi5tered 92harmaCis
(soniof1tk~Gal)esan ) whose date ofbirth is 18tbJun~ 1988 (NineteelllEighty Eight)
has been duly registered as amiddot
and is entitled to all the privileges granted under
The Pharmacy Act 1948 (Central Act No VIII of 1948)
as amended to regulate the practice of Pharmacy in the Stata of Tamilnadu
IN WITNESS Whereof are herewith affixed the $eal of the
Taniil Nadu Pharmacy COllncil and tha Signature of the
Registrar of the said Pharmacy Council
Note -(i) This Certificate shall remain in fCircetillgt~(illi Ffoibroary2021 days ofgrace uptoHhh May 20U T-fijS Certificate is issuoo afresh on l8022016
IL HE I
FORMshy( See Rule 79 (2) )
Registration ofAdditional QualifiICation (Under Section 35 of The Pharmacy Act 1948)
(he addItional 0(j)~jloma cerljicate c8Jegree a-ppearinsect below hers JJef1 inserl(~i in the C~~tfjter 0 ~hJJ111aciss_for the 1cfJ1tIi ~adll Q9)late t~tftA7j1J1 the ntD11e Sl the flCJ]f7Iflsect Cri(egi5tered 92harmaCis
(soniof1tk~Gal)esan ) whose date ofbirth is 18tbJun~ 1988 (NineteelllEighty Eight)
has been duly registered as amiddot
and is entitled to all the privileges granted under
The Pharmacy Act 1948 (Central Act No VIII of 1948)
as amended to regulate the practice of Pharmacy in the Stata of Tamilnadu
IN WITNESS Whereof are herewith affixed the $eal of the
Taniil Nadu Pharmacy COllncil and tha Signature of the
Registrar of the said Pharmacy Council
Note -(i) This Certificate shall remain in fCircetillgt~(illi Ffoibroary2021 days ofgrace uptoHhh May 20U T-fijS Certificate is issuoo afresh on l8022016
IL HE I
FORMshy( See Rule 79 (2) )
Registration ofAdditional QualifiICation (Under Section 35 of The Pharmacy Act 1948)
(he addItional 0(j)~jloma cerljicate c8Jegree a-ppearinsect below hers JJef1 inserl(~i in the C~~tfjter 0 ~hJJ111aciss_for the 1cfJ1tIi ~adll Q9)late t~tftA7j1J1 the ntD11e Sl the flCJ]f7Iflsect Cri(egi5tered 92harmaCis
