Faculty/ SR/ Tutor/ Demonstrator Declaration Form
Name of the College: Sapthagiri Institute of Medical Sciences & Research Centre, B’lore-90.
Submission date _ _ / _ _ /_ _ _ _
Note: It is the responsibility of the Dean to ensure that the submitted Declaration form is ONLY of a Faculty
member who is working as a full- time employee of the college
Attach a recent
passport size color
1. Name of Faculty: (Last name) (First name) (Middle name) photograph with
2. Age & Date of birth: (Years), / _/ signature and seal
of the Principal /
Dean across it
3. Present Designation:
a. Appointment order: Certified copy of order at this institute attached: Yes / No
b. Department:
c. College/Institute: Sapthagiri Institute of Medical Sciences & Research Centre, B’lore-90.
d. City / District: Bangalore
e. Appointment: (i) Regular / Contractual /Ad-hoc basis
(ii) Full time / Part time
(iii) With Private practice / Without Private practice
f. Date of appearance in last MCI/NMC assessment:
i. UG / PG / Any other:
ii. Name of College:
iii. Whether appeared and accepted at the same College:Yes / No
iv. Whether appeared and accepted for the same designation: Yes / No
v. Whether retired from Government Medical College: Yes /No
vi. If yes, designation at the time of retirement:
Signature of the Faculty Signature & Seal of Dean
4. Complete Residential Address of the employee:
a. Present:
b. Permanent:
5. Copy of Proof of Residence submitted and original verified: Yes / No
(Only copies of Passport/Aadhaar card/Voter ID/Passport/Electricity bill/Landline Phone bill will be considered)
6. Contact details:
a. Office telephone with STD code: 080- 22188700
b. Residence telephone with STD code:
c. Mobile Phone Number:
d. Email address:
7. Date of joining the present institution: / /
8. Joining report verified / attached Yes / No
9. Have you attended the Basic Course Workshop (BCME), Curriculum Implementation Support
Programme (CISP-i/ii/iii), Advanced Course in Medical Education (ACME) for training in MET:
Yes / No.
(If Yes, provide certificate/s)
a. at MCI/NMC Regional MET Centre: Yes /No.
b. at your college under Regional / Nodal Centre observer ship: Yes / No
c. Any other MET certificates may be attached
10. Educational Qualifications:
Name of College & Registration number Name of State
Degree Year
University with date of registration Medical council
MBBS
MD/MS
DM/MCh
PhD
a. MD/MS subject:
b. DM/MCh subject:
c. PhD subject:
Note: For PG & Post PG qualifications, particulars of Registration of Additional Qualification certificates
are to be furnished for them to be accepted. Strike out whichever section is not applicable.
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11. Copies of educational qualifications:
a. Copies of MBBS & PG Degree certificates verified and attached: Yes / No
b. Copies of MBBS & PG Degree Registration verified and attached: Yes / No
12. Details of Teaching experience till date:
Designation* Department Institution From To Total
Junior Resident _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
Senior Resident _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
Demonstrator _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
Tutor _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
Asst. Professor _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
Assoc. Professor _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
Professor _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
_ _/_ _/_ _ _ _/_ _/_ _ (y) (m)
* Write NA (Not Applicable) for the designations not held
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To be filled in by personnel from Indian Defense Services ONLY:
Designation Institution* From To Total
_ _/_ _/__ _ _/_ _/__ (y) (m)
Graded Specialist
_ _/_ _/_ _ _/_ _/_ (y) (m)
Classified Specialist _ _
_ _/_ _/_ _ _/_ _/_ (y) (m)
Advisor _ _
* Note: Documents in support of each posting to be furnished for verification
13. Have you been considered in UG/PG, MCI/NMC inspection at any other medical
college in a teaching or administrative capacity during last 3 years. If yes, please give
details:
Designation Subject College Dates
14. Number of lectures / small group teachings/ self-directed learning sessions/ clinics/
etc taken and topics covered in last academic year (attach additional sheet, if
required)
Sl. No. Date Lecture/ SGT/SDL/ Clinic/ others Topic
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15. Details of employment before joining the present institution:
a. Name of College/Institution:
b. Designation: Date on which relieved: _ _ / _ _ / _ _ _ _
c. Reason for being relieved: Tendered resignation / Retired / Transferred / Terminated
d. Relieving order issued by previous institution verified and attached: Yes / No
16. PAN Card Number:
17. Aadhaar card Number:
18. I have drawn total emoluments from this college in the current financial year as under:
Month / Year Amount Received TDS
Jan/ 20
March/ 20
April/ 20
May/ 20
June/ 20
August/ 20
September/ 20
October/ 20
November/ 20
December/ 20
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19. Number of Research articles in Indexed Journals:
a. International Journals:
____
b. National Journals:
____
c. State / Institutional Journals:
____
20. Details of other publications:
a. Number of Books published:
b. Number of Chapters in books :
21. Any other information/ achievements/ patents:
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22. Oral presentations: in zonal conference:
State conference:
National conference:
International conference:
23. Poster presentations: in zonal/ State/ National/ International Conference.
24. Awards/ prizes:
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DECLARATION
1. I, Dr. am working in the capacity of
in the Department of at
Medical College and do hereby give an undertaking
that I am employed as a full time teaching faculty, working from _ _:_ _ A.M. to _ _:_ _
P.M. daily at this Institute. If required I attend emergency duties.
2. I have not made myself available to any other Medical College/Institution in any discipline,
in the capacity of a teaching faculty, administrator or advisor in the current academic year
for the purpose of NMC/MCI assessments.
3. I do hereby solemnly declare that (tick the applicable clause):
a. I state that I am not doing any Private Practice or working in any other hospital
during college hours.
b. I practice at Nursing Home / Clinic / Hospital
in the city of in State and my hours of private
practice are from _ _:_ _ AM/PM to AM/PM.
4. I am not working in any other medical/dental college in or outside the State in any
capacity: Regular/Contractual/Ad-hoc or Full time/Part time/Honorary.
5. I declare that I have provided all details with regard to my work and teaching experience
and no information has been concealed by me.
6. I do solemnly declare that all the details/information furnished by me in this declaration
form is absolutely true and correct, and all the documents/certificates that were made
available by me for verification or have been submitted by me along with this
declaration form are authentic. In the event of any information furnished or statement
made in this declaration subsequently turning out to be false/incorrect or any document/s
or certificate/sis/are found to be out of order, or it comes to light that there has been
suppression of any material information, I understand and accept that it shall be
considered as gross misconduct thereby rendering me liable to disciplinary and/or legal
proceedings. It might also lead to suspension/cancellation of my Registration with the
State Medical Council and/or removal of my name from the Indian Medical Register.
Date:
Place: Bangalore.
(Signature of the Faculty)
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ENDORSEMENT
1. This endorsement is the certification that the undersigned has satisfied herself/himself about
the correctness, authenticity and veracity of the content of this declaration form in its
entirety and endorsed the above declaration as true and correct. I have personally
verified all the certificates/documents submitted by the teaching faculty with the
original certificates and documents that were submitted by her/him to the Institute
and confirmed the same with the concerned Institute and have found them to be
correct and authentic.
2. I also confirm that Dr. _ is not indulging in private practice
of any kind or carrying out any other professional or other commercial activity during
college working hours, from _ _:_ _ AM to _ _:_ _ PM, since she/he has joined the
Institute.
3. In the event of this declaration turning out to be false or incorrect or any part of this
declaration subsequently turning out to be false or incorrect or it comes to light that there
has been suppression of any material information, it is understood and accepted that the
undersigned shall also be equally responsible besides the declarant herself/himself, for the
mis-declaration or mis-statement.
Date:
Place: Bangalore
Signature (Head of Signature (Head of Institute)
Dept.) with official seal
with official seal
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CHECKLIST
Sl.
Documents Submitted
No.
1. Recent Passport size photo of Employee, Signed by Dean/Principal of college Yes / No
2. Photo ID proof (Govt. Authority issued): Passport/PAN Card/Voter ID/Aadhaar Card Yes / No
3. Certified copy of Appointment order of the present Institute. Yes / No
4. Proof of Residence: Passport/Voter Card/Electricity/Landline phone bill/ Aadhaar Card Yes / No
5. Joining report at the present institute. Yes / No
6. Copies of MBBS, PG, PhD degrees (as applicable). Yes / No
7. Copies of MBBS, PG, PhD degree Registration Certificates (as applicable). Yes / No
8. Copy of experience certificates of all teaching appointments before joining present post. Yes / No
9. Relieving order from the previous institution/posting. Yes / No
10. Copy of PAN Card, AADHAR card Yes / No
11. Letter head (in case of teachers who are practicing) Yes / No
12. Copy of letter from affiliating University recognizing as UG teacher Yes / No
13 Copy of letter from affiliating University recognizing as PG teacher (for PG assessment) Yes / No
14 Copy of MET certificates: BCW/ BCME/ CISP/ ACME/ Others Yes / No
Signature of Faculty Signature of the HoD.
Date: Date:
Signature of Head of Institute
Date:
NOTE
I) This Declaration Form will not be accepted and the Faculty member will not be considered as a
Teaching Faculty in case any of the documents listed above are not enclosed/attached with the
Declaration Form.
II) The Faculty member will not be considered as a Teaching Faculty if the original Appointment letter,
relieving order, Experience certificates, Government Photo ID, Degrees, Registration Certificates,
PAN Card, Aadhaar Card, State Medical Council ID (if issued) are not produced for verification at
the time of assessment.
III) Faculty members must submit the revised Declaration form in this format only, Submissions in the
old format will be rejected and Faculty members will not be considered as Teaching Faculty.
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