NAME OF THE COLLEGE:

DECLARATIoN FoRM : 2ors-re - RESIDENT SRYJR

(Nor : ri is csPoreibitity of Dan,

:nd ",;iins a, r, ,imr)

r.. r,." )r..Na:ry1 .lS'.nArL. leNlp .r.(b) D,botBir&&Aec....ari e.l.:.lj14...... J.2.yar)........ ..r.(c) subnn Phoro rD proor nsued by colt Auitro ri6:

Pholo ID subnifted;rArpoiopy/ raN crd/ vot; tDlAJdh, ctud.\';F. NiAoLro{.," . r","J" ,g..,r f

NoF: ir wnhour fnoh rD. Dpltrdion forn !i be pj4pd and r,1 nd be lobid.,ed sbr.hinS flulry.2l or.&n,l (pailkd.srp hindJro4 b' veri6.Jrion./!llCedi6c..evDocufrenrqcediriedTrrnsrarions, nus b€1. English

1.(d)ii.

wheiher appeftd_rd aaepied in Lsl MCI uclPc Assment on 5ahe

Campus / Praentiddrcsof

\<M<.r MraD\aAL .6LLl:d e. irFsl rv: ^rr

(t )Fe.I € RE/MsN6<<eRy

,{^

Penanenr Addrs of Reidenrt.2tr,^rr

/2A/ 4^/7a,nF ^/t/.

/p t

a4/ ///// - z /.ltotcopy or RdoD Ailotmenl LaEE an mf,fr-hed. t/ No.conhctPrri.ulan: T.l(ofi.e): ^14r ,re ?rp, Fi&sTDode)'rel (R6iden.el /aai- ,pq ?rr,

Dib of io n,ns preqr Ebtubonro n'ns rcpod.rbepcenr iNbtub aErhc+>!-/ NoauaMiGdom, MBBt j MD( RqDio blecnNoslS

Nde For PGPod rE qualifi.ation addiiional ReSiskation stiticare parricutaE be tunished andsubjet be tumished widin brackeb aiier scoring out whi.h?ver is nol appticable.2 (a ) copics of Desree cedifi(.tu ct MtBs and PG de8r.e rhached - v.462.(b) cop'e6 ol Resiftarion or MBBS dd pc deFee attiched rr</Lb

MBBS

Rp7/vJ33t3

333t3

nptdk or Lrrc rci.tung e\per en!e brl Ll:r.

,r.G) Bdde Finft3 PFPnr nsriurjon r

cGN LoR D I:9 D.: NT and rclicvcd on 2? ' .)+ -2-16 aJicr

Eisnins /rrareferins /(Reliainsords is endosed fron the previoG i.srirrlion)

5 rh..i.i' +i okl\hPndLomrh.\,o -9".,1.., rnrfrJl J)"d i.rdpr.

122 4\q

M WIMS,\NFYAIiFb

I

r,Dt. NAlAtl /.nt.t /4tlh) ^n

w.tk\nt rs .ar AltnR Rf5l ttrr\itIteDepa'6^r at eap. A/tu tur. ar, o teg".,' d do n-'.\, . r. dn u' d, L'Lnc r\r I "T d rrr' re ?"grh BFilrd i,

Resi.lenc Ho*cl in thc coll{e premkesIurihcr, I {ar. thar I am nor doing ant lrivat practice or .ot lvorking in my other hospihl

I have noi work.d at any .d'er medi.al .oll.gclisiituhon or plAdnbd mtse[ at anyA566mentin ihe curcnt r.adcmicy€rrr is dehrd ihat cach sb€nent ard/oL conbnb of thn dedaration and /d dNunenb,c.rhfi.acs subnjted along lnh ihe d{laati.n form, by ihc und.Fisndl a.e absolutelytuq cored and auih.nti. l'\ thc cvcni of lny si,tenent ma.le in ttds d(lrr*nrisukequendy tun,ing oui to b. in.ored o! lal* the underigncd h,s undd6bod an.la.cepicd ihri such nndedaration in nsp(t io any ..nGnt.f this d(lrniion shrll ,\o rPtciied :r a grc$ nis.onduci thereby renddi.S $e und.rsigncd Iiible ro! nsesarydrciplimry a.rion (hludins tn.vrl or his name Iton lnd'm Mcdical Rdcnt{

SICNATURI Of THE RISIDENT

This endorement n ihe .ertili.ation Lhat the unde6iSned has sabsfied hmsell /hePUaboui L\c odhe$ and veraciiy of ca.h .onhnl ol L\js dedarahon ,nd eidoxes incabovenentioned dedarahon as buc an'l corsL I have vcnfied the.efriricrkvddunensslbmiff€d byrhc.ddid're with rhe dginrl .ertifi.atey dmrncnis $ subhihed by th.Rcsident io rhe irditutc rnd sith rhe con.erncd insiitute and have found them to be

Reident (ic. for 2a houn) and$aymg in Room No. J3 A

2 In rhe *ent .I dris ddarrhon bning out b It eiihe. in..r€t or my Pai of this

dEbrarion subsequcnrly tufring out ro be incolRt or lalse it is undc6bod 'nd

a..aPied$rt $e undcrignetl sha11 also be cqually rdp.'sible besids the ddlarani hinseu/he6elrtor my such hbdelarabon or mn*abmeni

-'/4eY.

or caiiying oui rny other adiviit and ir' Hostul r colle8e premis6, sjn.e he/she

CounbBiBned {iih namp by $eDnedor/Ddar/Pri'r.ipal

t

s!t!. a1[.t/ra/l

"rU2'/CounreFi{.d Firh nrmp bi Daanl ftin.i!J.s3!qo.},,o?-t11.

.:.'Siened &verified bv the Assessor :

Na!!:

The Declaiation Forn wi,l nor be ac.etted dd the pescn will noany or the above dftuhents a.€ not endosed / fiadrcd with rhe Dedaation Foin.Thc pcson will not be counred as a R€side if rhe oriainal of Pholo ID proot n%idrrtioncerifi.ares/ D$ree cerilicates / PAN card / Mcr shd rD cdd/siatc Medi.al councilID ( if issued ) are not produced for verifi.ation .t the tin€ oI ass€ssnenr. ll the Resident nEt subnir rnc rcvisca d{lldion form in thi3 fomrt onrt (anydedrr ion fom subnined in a. old lormt will not be r..€pted and he *ill nor be counted

--4;YYY'Siqe.l bv rhe rIoD:P4ei o 9-o?^R

RRni Pasp.it size Phoro nrth<Emplo)c.s'Bned Ly De"n ' fnnopJl

Photo rDproof issred by covl Auihorihes : pa$p.ir c.py / pAN ctrd

..r "rJ opF orp'e erreppo r'ncn' o de' Jr r'-efl ir'rirdrc.Copr ofAlloh, ' tprts-b] D.d d.p,v ap'$r.F.d"'/du-'..copy ol raspon /voisrtard / rlecri.iiy Bilt / T"rqrl.* BilTAadhrCardarta.hed asa pr.olorpeftanentrcsidenceaddBilo iing tsln*atthe pr(enrnLftuecopies ol De8iee ce irnatr of IIBUS and Irc desrecopresol F%uLrti. r ol MBSqinJ PC dcsre.copy of experieNe .eititi.ate Ioi all appoinhcnb held belo'e j.ininS

Perievinsorder fr, m rhe prfl'ou5 '6btobon

INAME OF THE COLLEGE tl

DEGLARATION

(Nok: ri;resPusibili9 orDa4

r rn,j horLnsr5 fufl riheJ

\.* ^, .! 47!' "" ..r..11,."o1B-ln& Asc.. I l tttr ). ta$, . .....subnnlhoroID proof ssucd trI covr Aqdioiiie:Photo ID subniftedr ,/P6<pon.opyl r^N cr'l/ \ ot4 tD/AJdhii crd.Number As4.l?&/ c{ ..... r.-e.r\ (.{.L"

r'\tu@,,/, 1N4,, .Noic 1) wftholt Photo rD Decldrtion form will be iei{ted ,nd l;ill norr€achins faculg. 2) orjsin:r certili.ates,re hddarory r; verificdion. A

ce4ific €r/Do nenq/cenified Tbns,ations, nusr be jn Enslish

PrpdDesig.aiion: .!nr!'r- B.x,Ji.,Fp

Dt/

Pclqn) othcr ^sesi,ent

5ar McI - uclr€ Asc$ncnr h rhe n-e

in ri{ Ilcl L,c/rc

crnp6 / Irent:dd16or pcadenr

;:';'l;lll.""d'

1.(f)

' UhLUv!L ,t|d 3.1 4"1'l cL',a,ld,.Il<"+.-J, L?.a t.

-r,n-""a4r"..coniadPaticulars: rel(oflke) 6, 43'- r, 4: tu, (w'hsrDodq

voo hNurbc- 94?(r tr^1, w

lLl, DdFo JoinnspF.1r r,trrutrtr -l

ld. o!L+ - Sii.l &q/Jr (i) loiningrcpo ar the prst iis'itu€ atuched !,4Noz auaffioboB B Eql nM RD

Not€: For IrGPct rG quat6..hon additional R+istaiion ccrtilicate Parti.ula6 be lunished andsubj{t be fumished within bnckeb albr scorins oui whichever n not apPli.4e2.G) copie6 or DeCr* ced'ri.ates oI MBBS md Pc degr€e atra.hed - glteb2.(b) coples or Resi*arion oI MBBS and Pc desree atra.h€d l9yNq

8.\,'44;t'-t'

c^Lo,t - ller lrfd{ ,,,< .R-4.,4

c"""t.l

,d1i, Ll6l.)

hib of tE teachtng spaierc rilI dah.

Eisnns /Tdsfairy /E€liRina ordd ie €n loeil ton ah€ prdiour i$tltuiion).

5, I hav€ dffi lotal 3dpqd frcm dir 6lle8€ in iiE cora* lnlfti,l yed 6 Dder.

Af' tyr)

gl 3d 3

lrny 8fi

DECLAN^TION

t,D' PJ 1ii"il."" ,ij a" r-ery s,* $

'ndsbLns $i I

| "it) | tt).,,| aj iGa .Dd :m

Rcld€nB Hoskl i $c'ollcgdpr'dse';:"":t.i:::i"l'"]'; :::#;.',.' . "," "''

. - - "' '*ine a dv od e \o'piur

, iiXiiTiT.";*"" ", ,.v o'n€r mcdnar correse/i*tituiion or p€nbd mvscu at a'v

Asmenr in tne .unent a'ademtr Ydr'i iT";i['"T ""j

; .;l;:;' "i t ; -. b or $' d ]''bol

::"^, ::"'r-"J:,;;',:i;;ll.[T,ff 'J : ::; :]i ; : ":,";; ";. 1 li1 l1.l-:"":r"*:l:f.;:;,"":T.T:i';;:;: -:, :i; ^";, .' ", -"ri-]i",ll .*"li*"lll,',.":1".1 il"J;;li " ". ....',.i ",

:".^'.",^'a,,:flj"i.,."lljll:j"1 ;;"i;:;""1':' ;:;:i';i;;,;;, 'r"'"r,i - a*.'.

" I ,.r.t i:l::i, *:l.J:' ''*'lll"l .+,i, ;,' 1"a" ' '*"''ir'"'*"*

r'd" ' v"d- 'ic

$

!ra€: Mqress qil' trNDSB$W

hL'd' 3Tr |' vori"o\'nFlt l{f

:ir ii; ;*: ;.:. :t: :,'i:,iti:i *l j: r,.:"rr;r""il"il;".l liLi',ili::;:lilil": ['i1",;:'9;:":;i, lTHi.";;; r"'" """''n'-''

o"

. al.o.odun u!. D, E,,,ud' - :,," . ... l;::::;i;i"1l,T.j:i,'1'.:;;*Ji i-j'J -'.':h!t ; T:i::,]:i: Ii'f ill"":;': - i"^ *-'hsioi'r€d drelnstitob'

| ' o"r|d dh' ' n '' 'i -. " i . ':.1i'":,'j":':j] i:1,:!'*';,";:":1,;::;Tlil ri;n:,:i::'i;$:1'1"'"*1:,;. ;: '";''

h tu L' '

1*

for any su.h nndedaraiion or ntssbbmeni

l*' r".-j;;fi;; D""r r' ' rodl

;i@;-opv / r'ANcard

' -:: : Lj4-Cenifidd copics orPresent a

-'mnr oder d prc*d lrllllls,

; or Allohent Lihcr bJ D991I ;r.t Drcn i re. denc^tdnsco-IreI P@'t /V.h' c*d /e"irk' c.'a au*ea * a p.!qr9!

il".t^-h Bill / r"l.Phtn" Ellrnanedi rcrden.e addE$.

ji--g -po*r tt" s**t 'uiruec-;;iDq*d."!!q!!!q4jg!,BGi.. iinGiGu or v ees

'nd rc d"s'*'

*ul--"* u' "tt "pp"'n_" t'cld bctore pioing

Faiflsd.. r,.. th" p*'.^' *b tu r"

-l

REM^RhS

!4si

sleroq o+,rj

Slls r

NAle

r:: ::l.-.';ri::lTJi:[,'.T.i:TflJ]il:T'" ;l"1ll: 3'j.ii:::;';: "'*-*""

FlH+rifrffii#i*iilli'ffi;:;

I o1-t?

/1'NAME OF THE COLLEGE:

DECLARATION FORM : 2oIs.rg - RESIDENT SFYJR

(Nob : rr *EsPonsibili9 of Da4

.rher oleaedudns:.admrc yrr

N,-"0...1:1V5.frr...11. ...+l.rj.jln^,/De ot Rtth & a}r. a 5 / 6 ] f .n t,subnii Photo lD proof i$ued bi covt AnL\oiibes :

Paspod oryl l^N Cdd/ vftr tD/ ^ddhnat

cxd.\umb,.^6 30 65tJ 5t.t/: r.."-b,6.^r o.."^.\tr r\ l\irhour rho'o tD. DRt&rion rorn wil be rejFdcd and E, -r ri oi.:a*earerhina f:(ulh 2r o-iainat c?rritn ate3 rc mfid,, ory fo. efifi.aiion. ax

Cdificates/Dotunenigc€dificdTraftlarim, hrst bei. Enstish

1.(d)iv.1.(d)u.

De",b*r. Q-,.^/. D.Aa"^, (,\

udh or dppedd, " i' L{ Mrt r c IE ^'

l 0l]r4 A$"+ n+.lltl ir $tuth

whd\q ippsFd ard ...ep d r ..n. v, t _ r c. |\ {..A\mr.rl}.vnewlerle rppa'ed d,r d pptsJ u rll Mrt. Uu t\: ^r.m.nr o,.dn.

t/t^( | \flFt aTt)^/ttr ^24^t^..1r.1 6a.s6,,

.*", *-,,*.

' l:-: ',r ii''

c:me6 / PEstaddssd:esLdsi:

We"l

P€menrAddlKof RgidenE r7 t+Al64 V-t .k nEN"r eual)L tt,,at a..,t.".n, {=<on^,

ned Gidp.,",r iddre$ e, mf di hed yA/ N..Pari.urars: Tcr(ofii.e): D/'?S, 22 :/?rp^

Dab ot joinins pl*ni insritution :

Joining repoir al dE lr6mr imiibteaMMihE rc: t4 gp2 9/ r4 D q

Nft: For PGPosr IrG qutilicarion additjonat Reaisbation certificak pdricutaF be fu.nnhed and!ubi,T' b€ flm.t-d s - 1b-d. ehath' qorugolrwr(hdq brorrppthdblc,2.i,, copjerof Deg.ccpnificks of MBBS.nd rc des,ee dr!hcd: kd€2 (b ) copies or Regiehrtion ol MBBS and Pc desree afta.hed Mr€

Dd: l\ of the ha.hng e\perienle hl Jire.

4.(a ) Before joini,rs presenr instturjon r

9e. ?c\tDtl taNas v.tkin. & y cN€fcfA t..p1..1 ."t@s

aftret'Jed o^ 2+f c2f 2at7 attr

TtL DAre 4 ^4oNtt|

r6igning /Trturoins / Felicvina order G endosed fron the previous itutftution).

r have dna n robr sripend frod tha corege m ihe curcnt tinancial year as urder.

qA..N st t

an "Oli,s r <e P!1ncry- -rheDeparh€ni of pAn,)rr'f-,...,( ar rz4lr McdicalC:rllqe and do hcrcby givc an udcrtakng L\ar I an a Fuu rine Re3llr Raident inE^4/1 r)t--,.^t .nt r F6c . and 'n sbyins h Roon No. -r< R in $.

Rsdenb' Hctrl in ihc collese Dremises.Fu!6er, I sbie that I am nor doing my Pnlat practi€ or noi workiry in a.y

r havc not workcd ar any oiher nedi.al .o ege/instituhon or presenredA$e$nent in the.uftnt acadeni. ycar.rt is d{lared lnai eadr dabnenr and/oi.onienls of rhjs d(laniion md /or dmuncnb,.erhficaB subniftd along wiih rhe declararion lojf, by the under.igned are,tsolukty

naimenr mad. in L\is deddaiionsuk quendy bmine oui to bc in.orcd or fals? rhe Lnde6igne{cpied ihai such misdedamhon in Fspe.t ro any .onhnt of rhis deraranon shalt also bcteaie{l as a gros mjs.onduct thcrcby rmdering ihe undeBigned liable lor neGsrrydieipliniryiciion (induding removal ofh,s namc hom Indim Medical R%ise4.

'Ihis mdorsemcnt n lhc ccrbJtrahon that ihc undcrci8ned has satistied hinsell /heRr,bo!t the .oiietn6s and lera.iqr of ea.h contunr of thjs dc.larahon md cndoss thcaboveneniioned dedaarior a tue ard corecl I hrve veiiri€d the @di{i.n.q/ d&rn€ntseubniited by the candidate *ith the original .enificatey' d(nmenb $ subnifred by theRe5idenltothein*ilul€andwithihe.on.ernedin*ifut€andh

I also conlirm ihar Dr. flu9JnE, rAtaAlv k aorking 6 full dme R%ularRdident (ie tor 2a houn) and is not practicing or .artying out a\y o$er adivjly and issbyinS in Room No., a & ot $e Reidenb Hossl in collqe prenb6, sin.e he/shehas joined the Imtituk.

2 In ihe event of L\G d€la.ahon bming out ro b. eirhe. in.orqt or any pai .I thitdelaiation subs.qLe.dy tuining ndenro.d and a.epbdthar rhe undcrsigned shall also be cqually reslEmiblc bcsidc ihc d(larani hin*ltlheEelff or.ny such nnd<bEfion or mn*abhanr

-l-_

le.e e1ll, Counhrigncd wiLh stup by

Dnebr/D@n/Pdncipal

-"4e,

of ihc collcsepnob rD proof issued by c.vr Auihdftics :E;F.t cottr-:\N crd.rnil:ed. opre of p e en' Jt t rl.rrc I o Ja r r€ e i'n . L r.op. of

^l op " i er,' br Ded "! p',.r or p'F, n +iop1. .4no,d.

c.py of Pr$por /vote. Cirdiadhar Cad ata.h€d d a proor

/ Eh&hi! Rj / rergphlm ritlot pcmancn r rcsiden.e addFss.

5. loinins rep.*af rhc prcsc' r i' +ir!tscop'cs oI pear*.erhh.arc orMBBsind rGdcsrc.vp'6 of F€CBbdb.n orMBBSrd Pc deArecopy of cxpcicn€ ce{ili.aie rd alt apponrhenb hetd tdorc joining

nele\ ngordcrfrcm il epre\ .usrDhtuhoncopyofA3dharcard

Si€ned b! rhe R€sid€nr:o+:cl*f t,t 7

-- -''x49ye-sisned bv thc HOp:

/*counr€rimed sirh st no bv pcm / frinn6t.

sised & verilied bv ihe se*or:

NSI!i

The Declaration Fom will noi be ac.epied tud the pcson will not be.ounied.s Residenr ifany of the i bove atru me nb ar€ noi encloed / ara.hed wj th the De.trarion Form.The pc6on wil nor be.ornted is I Rcsidenr if ih€ oricinal of photo tD proo, Regjshrtionccdifi.ares/ Desree certilicates / PAN cad / Mcr snan rD cad /€hre Medic,r councilrD { if issu€d ) re nol tioduced for vedfi.ation al the tinre of $sessnent.AI the Residenr hr* subnii the revised de.laration forn in rhis fomai only. (Any<red,arion forn subni hed in m ot d format w l nd be r.ccpred and he $ il I not be .ounr cd