KARNATAKA STATE PHARMACY COUNCIL

st

No. 514/E, 1 Main, Vijayanagar Club Road, R.P.C. Layout,nd

Vijayanagar 2 stage, Bangalore - 560 040

Ph: 23404000, 23383142 Fax : 23202345 Web : kspcblr@gmail.com www.kspcdic.com

The following documents have to be submitted along with a fee of Rs._______ in the form of K.S.P.C and

Rs._______ in favour of K.R.P.W.T.

Encl : 1. Form “G” - Scroll down

2. Declaration

3. Information Sheet

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 support of Date of Birth with one

A4 Size Xerox Copy)

4. Recent passport 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 /

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

1,050/-

2,500/-

E-mail :

INSTRUCTIONS TO OBTAIN REGISTERED PHARMACIST CERTIFICATE

B. Pharm / M. Pharm course for the admission year of the student.

Applicant for registration.

Timings: 10.00 a.m. - 1.00 p.m.

FORM G(See rule 48)

APPLICATION FOR FRESH REGISTRATION OF PHARMACIST (Under the Pharmacy Act, 1948)

To,

The Registrar,Karnataka State Pharmacy Council

StNo. 514/E, 1 Main, Vijayanagar Club Road,ndR.P.C. Layout, Vijayanagar 2 Stage,

Bangalore 560 040.

Sir,

1. I request that my name may be registered 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 Registered 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.

Your faithfully,Place :-----------------------------

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

Signature: -------------------------

-------------------------------------(Name in Capital Letters)

Specimen Signature of the Applicant

1. 2. 3.

Siganature

Karnataka State Pharmacy CouncilVijayanagar, Bangalore 560 040

8. I am enclosing a D.D.No. ........................Dated ........................ Of Rs................... In favour of “The Registrar,

Karnataka State Pharmacy Council, Bangalore.

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

2. Father's Name (In Capital's Letters)

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

4. Nationality

5. Current place of work with full address

6. a. Current Residential Address in Karnataka State

b. Permanent Address

7. Year of Passing 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 Passing 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

12. Name and address of the Institution from where the Qualification was secured

Date :----------------------- Signature of the Applicant

Date of Birth:

Date Month Year

Ph :.................................................Mob: ............................................

E-mail :..............................................................................................:

......... ..............................................................................:

......... ..............................................................................:

......... ..............................................................................:

Ph :.................................................Mob: ............................................

E-mail :..............................................................................................:

......... ..............................................................................:

......... ..............................................................................:

......... ..............................................................................:

Mother’s Name (In Capital's Letters)

Husband’s Name (In Capital's Letters)

Per education regulation in force.

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.

I. NAME OF THE PHARMACIST

II. REGISTRATION NO.

III. FATHER'S / HUSBAND'S NAME

IV. RESIDENTIAL ADDRESS

V. DATE OF BIRTH

DATE MONTH YEAR

VI. BLOOD GROUP

AGE SEX M F

VII. OFFICIAL ADDRESS (PRESENT WORKING ADDRESS)

VIII. QUALIFICATION CODE CODE

01. D.Pharm 02. B.Pharm 03. M.Pharm04. Ph.D., 05. Qualified Person 06. Other specilaity :---------

XI. PLACE OF PRACTICE URBAN RURAL

CODE

01.Chemists & Druggists 101. Private

XII. OTHER DETAILS

D. Pharm Certificate No.

YEARS

Tel / Mob:

E-mail:

&

Note : USE CAPITAL LETTERS USE MARK WHEREVER REQUIRED

Name or the Institution & Address

Name of the University

PIN CODE

( Mr. / Mrs. / Ms).

Tel / Mob:

E-mail:

PIN CODE

02.Teaching 03. Administration 04. Hospital 05. Industry 06. None

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

109. Any other profession, Specify .........................................

108. Unemployed

107. Zillapzrishat

106. Corporation

B. Pharm Certificate No.

M. Pharm Certificate No.

Ph.D Certificate No.

Pharm.D Certificate No.

Year of Passing

Year of Passing

Year of Passing

Year of Passing

Year of Passing

Information sheet to be submitted with Form G

DECLARATION TO BE SUBMITTED ALONG

I. I ................................... hereby declare that I have not registered 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 registered my name in State Pharmacy Councils

detailed below.

Name of the Qualification

Registration No. Duration

From 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

And Date Pharmacy Council

WITH THE APPLICATION FOR REGISTRATION

Registration

KARNATAKA REGISTERED PHARMACISTS WELLFARE TRUSTRULES AND CONDITIONS FOR ENROLLMENT IN THE TRUST

1. Candidate must be a Registered 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 registered in the trust.

3. In case the Registered 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.

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

7. BLOOD GROUP6. MARTIAL STATUS

8. ADDRESS (permanent)

Preferred Mailing Address

MALE / FEMALE

:

:

:

:

:

D D M M Y Y Y Y

:MARRIED / SINGLE:

:

:

9. NAME OF THE NOMINEE

10. AGE & DATE OF BIRTH OF THE

11. RELATIONSHIP TO THE APPLICANT

12. IN CASE OF MINOR, PLEASE MENTION

GUARDIAN’S NAME

:

NOMINEE

:

D D M M Y Y Y Y

:

:

13. ADDRESS OF THE NOMINEE :

13. MODE OF PAYMENT DD / PAY ORDER NO. ..................................................................................... :

BANK: . .................................................................. PLACE: .........................

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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

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For office use only

MANAGING TRUSTEE

Note : DD to be sent in favour of Karnataka Registered Pharmacist Welfare Trust, payable at Bangalore

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

Verification remark by office:

Enrollment No. :

Affix photo of the nominee

: Specimen signature of the Nominee : 1.

2.

3.

Yrs

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