NAaii'E OF rHE COLLEGE, kMaT N(01(41(olL+nC NANA$'R|

N"ft., 4c71.4...731.aq . k,ued by

Note 1) Without lholo lD Dechdion lom wtu be reieded .nd rill nd be .onsidsed 6teehing facdty. 2) Oiiginal Certtfi.ate d. n darory for vdift.ariotr AllCeni{i.areyDtrunenrqcefifi€d Trdslatioru, nust be in €ngtth

1.(d)i.

r.(d) iii.

1.(d)iv.

1.(d)vi.

1.(d)vii

Naiure or appoinlrne.t (a)(b)(cl

Resurir / c.ndrrurl /Adho.Full time /fa* hme /Honor.rywnh or wrthoui PrivaE Praqrie

mether appJxPd and acepted in Last Mcl - uc/m As€nent in llE same

w\cthe' appa'r! ri d icphd n ldr MCI - UG/IC

Wherher yon llave reti€d frofrD6i Enation Jl24Erz-t. /h?

DEGLARATIoN FoRM : 2ors-{9 - FACULTY{Nd.: n i6 apotribiri9 of D6i, HoD & fi.urry ro surmii onty th.d€dmrion fon off ulty rfioir3.ot rppeaedrorrsxsnentindy

i d w.*ine rs full d4ei

' p/ .u,-" 2 .nA 42t't' .4.r.40iA...... . ...

r.pl o.corni,,r'aeg".....? LJ:.: 1.1 5..e..../....6{-tkz

1.(c) Subhit Phobo ID pr6t isued by CovL Authorfti€:Photo ID subnited: v.P.56r6*€?r/PAN crd/r&r€:Irv+id}*tu

X.1.t!t!*.1;.

,,*'*",s *^, 2nfo* a^t oalce*ified opids or prgeni appoi'rhenr older it pr*nt iGiibb abched. /zl

Govermenr medic: collg3e - Y6 / No It !s,6tu1 h&ara"//.r. t<or?/ 'r€ A[6Lt

/9

f/t utti

1.(e) (b) Pemt Reide.rdl Add€6e of Enploye:

ro4uJ lAeva4'rt )tttL"t

1.{4 Have you sdqgole Training in "Bsic Couse Wdkho/ at Mcr R.gioEr cenEeii\Et or ii gour @lleAe undo Re'@tul CdtE obffiGhiP?

Tel (Reidene): ---]zJa!-----:-!l-f-:!:

l. td copy ol B.s5poc /vet€:4rn / E:9.try3x+/r:!dli& TdePf,osixr / Aadhx c.d /d.ched s. Dof of stdere, *gNo

conbLtpdtuhd td\otti.e: 0)!L{1L!ZZ:ZI2r.ft)

1. (D

1 O

Dat! olioinjng pll(gt iretitudon, 3 O2 J4.,

lomeEporatuEp6sr i*t*"*,*** -";/^.

Date rtul plae 6f tt iJ\ENde oI MCI R%ionrr C.nke whereTtuininewas a@/t t$i"ing@B datu ln@lLg.,gibthe.let ib olth. bhfli

(&otts /6

qa' 7Tc Nr

d/us/oNe i ' ^/a4/' !/2.

NJ^!LbW /s ?r 40t-7 TL14L

DM/MCh,AIC D

6Xu,l " ,.NaLdt'[W aALtL0r /st1 j(M(

Note For PGP6I ?G qualilidton additional ReSistmtion erifiGte Particnlm b€ tlmish€d ddtubjar braIErso'ingout Elxchde' Lnor''PPlj(ab.

2. (. J Copy of o%E @dili(at€c ot MBBS rnd PC d%re rd.(hed _ ]'aalJe

2.(b) copy of Resistration or Muu" *o "u

*o* **"* - "63 (a). Details ot the b.hins dPerjenc rilt dah.

NoF.- Tutor / Resident workins in Anesthesia ana R icdiignsis nu* halre 3 y€a6 te,chingexpendce in the respedive dePaftnenh in r rec€tjzed,lpef ited n dical itutitule to b€

e*fly,L t- t- 1q93 a yL ,rt rla,ll:

'l.f#,{1,r, i4'"J',*'l"lrura"lflt&(;,4r

&dtu! ul1q.f<lluz v slp/nK t4/L/lscl

t/4//912

"4 rJ

Nul"LJ'tu

N c httraea.c C.X"IN.c G0t"1'

e/t/toooI t'londh

5'1,'3r,J ,d/12

fuLr*l2lakott&k,t-h

a 14 , tltz

3,./) , s/t lsCt,4lta

codider a! *nior resident,

3(b). Io be tllbd in by Er ArnY Pssnnd onrY:

NoE: Have yd t€en dcidsed in dy UG/PG ispstion at anv orh'r i$tihtion/nedid one8e

ddingtdt3yds. y6, Pl6e give detaG

BdoE pile Dent itutitodon I sd worlirs at l7f,,"itu 1-hi, ,'d Fw.a "",/€,siins / €bnnB /TBn erins (R€lievi$ od€r te end*d frcm the Psioc

s. Nunberot R@rch rblicatiom in Indd lournak:

t{.) Inlermtiomllounals: ItrY

5. c) snah/Itutitudon.l IoMabJ

6. (a) My PAN Cdd No, i5 ALT/A 734o 4

e.a uy euanu,,-aNo. o 43qA 43Bt6ttro

6- (.) I rEv€ draM bbt dolumenb lrom tnis ollege in lne cuffit lilEnial veat d Dda_

6. (c ) (copy oI ny ?AN & Fotm 16 |rD6 crtifi.ats) for linatuial ,@r 2016'17 e€ atbctud)

DEe!4 !4rjON

1,

3.

4,

\D,. ALJUt4tLLaa!.-- "^ **n"ed

D"p't*,." ot Pa/',tI4F 4A;a,L at

Collqe ad do herebt Sive an undedaki'rg that I an a tull rine @.her i!/u/nk.r? nt /,-M wdam8 tom Y -A.M.blL P.l"tdd!)

I h:ve rct pEdted ny€lf io ant oih.r Medial Collese / Imrituuon $ a feultv /R€ident in the tuHt acadmic year for rhe PuPose ot MCI s63renrI an not h.ving privab pa.ri€ anywheP OR I am Pracbcing at

-nnE.tt!

ot Z<'Ltj tt1/.ha sd ny

hous of edde de 4& b 9la ru'tr'o t srac out r an lot doins ey P'ivaie

P6ctice or not wor*ing in any other h6Piial dlring college lbu$

Conpleb det ib wjt! rcgard ro aork dp€rience ha been prdid€d & nothiry hd b@r

I m rct vollqg in dy olhei nedical ox€g./denral couege in rhe Sbre or ouEide the slatsin any capncfty: Resurar / conlr{tul / adhd -- Full tin€ / Part tine / rbmr.ry,

1D5

Ir-qaoo 4F'0055500 4Goo

Ir is d<lded $at ea.h shement and/or @nienb ot lhis ddaatio dd /d d(xrDmrs,e ilic.b subnnred along with rhe ddantion fo@ by rhe udeBigre.t are ab.olu€ty

slb6tquhily turniry out bo be iNRt or lalse rh€ lnd€Bigned hE undeBrood andaepd lhat sqch nisd{la.rion in resr€.t to any Mrst of tnis detararion 3hitt alb betreab:l a a grcs nisduct theEby rendering tn€ undeGign€d li.ble lor nNrydi$iplinaiy a.rion (imluding Enoval of hjr lrme ton rn.tian Medical R+i'br).

3lz/vSIGNAIURE OFTHE EMPLOYEE

3,

L

ENDORSEMENT

Thir endoffi.d i5 rhe erlilicahon |nr the undeEjSn€d hs 6.Bfird him!.U /heEltdboul tF cotu rd vera.ity oI eJlh . onhnr of thi5 delaratid &d .ndos rhr abovemenboned de.laration 6 he and @reL I h.ve v€rified rhe erdf..r6 / dmn6bclb4jttcd by tfi€ cfdid,re wirh rhe oriSinrl cedifioreydmAetr s sbnied by rherer.hs to the Ituriture md vith the .on drtud Insrirut€ and lEv€ fond rhen ro 6e @€.r

hrbcutuntll^w. A k . iLllllk"tr ir rct pracri.jng or dnyins our

dy odE adiviS/ dn'ilg oll€ge workins hous i.e, toh __L b 4 sin € he/srE

Ir the sot ol thir dala.rio. lrrning our to be eidEr i@u*r or dy pad oI rhisde.Lration subs€qnenrly llming our b [e ircoret or tabe n is ud.GtRj ;d acpEddut $e und€dCn d ,hdU rlrc b. elually 6poN'bh b6id6 UE delarmr hinFU/hsetrIo' dy such misdeldrion or misrai€nenr

,u---

l

sid€d bv rhe T€acher:

DAE 1,2 )'1),t^.o'r rn" n'o, ffDzrg.l J/a2h --

sid€d & vsified bv th€ arssor :

S4e r

NSI&

The Dellr.tion torn Eitr not be r(eprpd ,nd rhe peFon wtu no. be reunred $ k hs i(Jnyofrhe.bove d*unenFre nd cn.jo"edlanfthed trirh rh. Ddt&rion t-orh,The.pe6on wirr nor be rclned i6 . re{he' iI rhe ariginal of phoro lD prool Regi\h.rimcenifiGb/ D€e.ertifiGF\/ pAN crd/ srire Medi..J councit tD rir i,euedi de ndprcdo.ed for verificatio. ar ahe rtne of ssessneniAll rhe terd€rr nos slbnit rfte Evi$d ddration foin in ihis foinai only, {Anydeda{ion forn subnjtted in .n otd foimi sill not be ac.epred .nd h€ wil nor be :ou;ka

REMARKSq.!!e

n*ent P6p.* rk phdo of the Emptoye. signed by D€arv

nhoro rD prcof i$ued by covL Aurh;u; , pep.;i7-?;ic,rd / Vokr lD / Addhiraardr'

f .,nd#."a* * r,**' ,or-h. dedP*d

copy of Prspod / voh/ clrd / flRE.iry B, / Tetephorc B,lt/ Aadh.YCi d / Dean s allobehl ttu atralhed d a pmt of

4(4 copy ot lFspod / voFr card / El-bi.' ry B, / T.t.phore B,n/ A.dMc,rd dbched ,s pref"r s,-"n.ni,6,d.*".

5. loininA r@n ar $e o6ent'Nriture.Cop,6 of Desre sbrcdB of M BBs and Irc degreCop,6otReAisb.honof MBBSand rc deAr*.cop, of e'p€nenceertncah fo lt h..hngappoinrmnb!:€rd befo€ jonjns p'*nt rctituk.Rel,fl ins order from rh9 pruviou5 nsbtuh;

Fom 1b (rp6 €d'c'e) ro, lhe tast r,;N,ar ttrL!ftr heJd {'n c6eofrga!l'e^ehorre pGLh(ins)Cop, of U.C. r@gnizsd bacher leh€r &om atfiliaredUnivqeity.Copy o1 P.G. l€ogniad €acher leHer fon afliliaredUnive6itv.(or P.c. assho9copyofArdhrC,rd

NAME OF THE GOLLEGE TM'1 4.) U

DECLARATIoN FoRM : 2or8-ts - FACULTY(Noh I Iii5c5posibilityofDerD HoD& fr.ulry b slbnit onl/ rheddlrnlionfornofhculty{hoh:

€r aid wdkiis s iull 'ing

r (a) N"* }? 6i^Jue4a c

| tu DJ.o.d*rrs As-.2.47..r2.:l:r8 ...?11,.r..

1.(c) submilPhoio rD pioolissu€d bJ] Govr aurtroriti$

Paspot .6pyl P'{N<a'd / rrds rD/ Aaah*tald

N"-b", ts- (? k1e99....... ......... rssucd by

Note 1) Wiihour Phob ID Dedararion forn yill be Ejedcd nd wirerhing fadlty, 2) Odginal Cenilic cs &. n drtorycdifi.ates/Docunent*Cedified Trrnsl ions, musr be in English

Cerr'f 'cJ.opLes

of prc*nhppor,

e"g,K7 c.",.*r,.r Taah-ftrllrme /r:rt ri'n! /Honocry!!rh rr wnriud fn\rrcPnd€

"", "", o'n* o**..*,djl7-.*,n

MCr uc/l'c ]$ssmcnr 'n

rhe same

whether app€aled ind i.coptd h L'st N,lct uc/r€ Assmenr

whelner you lllve nrtdd lroDr Covernedr mcdical.ollege _ t$ /

0 t^- |, 1,,]

k)

A.-'

1.(d)iii.

1.(d)iv.

-''-

Ptqt R6id6tial Add6of enprove:

AtNozt+1 . c{ e+:(\i t$+tL

r,k) O) Pe@t R6idotial Addrd ol EmPlove :

l+ve @ uddf,o* Training in Basic C'tM workdDC 'l MCI R€816t1C6be

iit o, i" s7* -u,8" ,"d- Reaiol4t cdtf ob*n6hiP11.(0

1. (s)

1. (ft)

1. (D

1. (i)

cow or P;od /voelcJd / qe*t€iq.six ,'Iridtr+d'?Mdl / ^'d!&4"d

/,d;hed s

' a@t or rc5id€ne. lttNo

conht?arttdld ret (offi€): a, Ct14 ) l q 3&-o-@6srD 'ode)

Dab oi joinins p,*d rtitution: 16 Y ?? 6

Joining repon .t the Prent icrituie athch€d - Y6/No

F.re or Mcl P€gidul c6Ee thseTntu;^s@ dw/ tf ttuinhAa.s dotu in@tt se,A". the d.taih ol th. obstuelftun Rc

DaR ard pl@ oI Faining

MI

Note FoI FGPo* r€ qualifiation additioml Registration errifi.ate Pa*iculd h. fuhished dd

'ubd be rtter 5rcrnq our vtuchqerb nor aPph 'bl"2.Gl copy oI Degrp cdiri(ds or M 33s rnd Pc desR JRehed,_ \qNo

2 (b) Copy or Registation of MBBS and PG desree atiiched - Y.s/No

MBSS 2a.2-2L\55a"ltl.s

MD/MS/DNB

s,hi-tiqd?l) 2. o,

ZLL193\tl Llol

-[cn'?Q

ffifrllnPlrl,lt

'o1't.Aoo4

3f4s3514h7 'f (ML

I (a). D€bk of lne b.hing .\Pefl6ce Ell die

lnct -=')te ttl4,s l4t1 l,l Ee"a'

14",1'*

Nor€r TutDr/ Resident {o*ing in Anestheiaerpeiiefte in the resp{tiv€ d€pdtnentsoneider as senid esid€nr-

and Radio-diagndie nuetin a eogniad/pernitr€d

To be filled in by Er Arhy Pdsnn€t only:

3.

Noe niv€ you b€€n coNidpred in my u6lm icptrtion at my orher itutibrion/hedi..r.ou%e

dunng l6t 3 yq*. r y6, pld€ give detnik.

l.t"

BefoR joiMg plEsr irotitoton I has worljng,r

€isni'rs / reri.inS /TraNredng (Retieving otd€r

5. Nunberol Raffh Dublicarioc in lndet loulDls:

i6 encl@d trcn th€ Frvlat

I

s. (c) slate/Itutitutionallounals:

e.1.y uyrar.rc.,a r" i. 4f4?l IL)(r!'

6. (b) My Aadharard No. i. lt\ 2-6, (c) I have drawn boial dolumenb l6m this collese in L\e.urent lindcial y.ar d mdf--

I

6. (c ) (copt or ny P^N & Form I6 ODs @rriricarp) Ior fi'Nn.ial year 2016-1 7 ire atbched)

DECLARATION

I r 1 l<{N!26, r

3.

Col,; .nd do h{-b.y C'\- ", L.J1 n.iE ri.i dm ,u.. rl,e tsalt-n m

L!tt1@)id FW ,. ,",d,,.- ? Av b k rM da.rr

atirrkr,Br*ure /I hive not p4mted mys.ll ro riy orhcr M.dicat co egc / Lsritulni as a facutty /R6,dcntinthe.ur€ta.idcmicycrrld tlre pu+,os.of MCi a$e$mcnr.

I io noi having private pra.rn! rnywherd OR I a,n pdciicing ai

nrany orrrrhuspftal duii,lgco .gehou6

reSard r. wo* experien.e has ben providcd & noitring has b€n

Fudhrr r d, re ddr I am nor Lj.i,rg my

5. IamNrworkinsinanyothernedicalcol.gc/dcnratdofiegein rnesraleoraubidetheShleinanv.apa.irr: R%ular/ conridil / Adhoc-- lull iime / padtime/ r tono. y.

TDS

l*aaot,AL50A ) ROan

It is declded tlut ach shtenent and/or ontenrs of thk d<laabon and /ar drue|',;;;ri."6 s,b-itral alo"g *ith tie d{ladtion torm, b, rhe undqsismd are aisluElvtue, colHt and aurtunti: In ihe event oI an, srabmeit nade in ttls d*ldli6

',L-,*rru n,^* o,r t * 'n.onRr

or la|* tnc undedigned hd unddltd and

.*,,:d ltEr s. h .i,sd6.-,h.n m FP{t ro,nv conrflior t}'s dal'''lionsh'll aho be

hri:d 6 a F6 nisond(l tAereby 'ddering

rhe undesisned liabl€ fd Ka:rtdieiolina riion (inclnding renoval of hj3 name fbn lndhn Medical R%isb4

I

1.

s,cN*fukw,,ovxs** Slltre-Pt^*, AtW)

!NSS49!M!Nr

fl\is endoG.n€nt ir lhe certitication rhat tne undersigned hd stLfied nimFr /he'Elfrbour tl€ .od<li6 md veiacjty of each.ontent of Lhis drlaation and endors dE

'bdenentioned delaBlion s kue .nd coret l hnve verified the c€difi.itB / dftd'nrgsubmihed by rhecMdidare w h rhe otigjnJ Rnifi..teddr!m.nts is 5ubnihd bv lhebJcher ro lh; h\tibh ind wilh rh.con<etned ln{itur€.nd hrvefoud rhm ro be @de.t

I rtso.ontim fidD' hNd0A'1 ( i.m,p'"(h-nsor..rryngout

my other acrivity dnins couese wo,kins houF i.e tom -elEplo 76l4stNe,EktehE joined lhe lroritut.

3. In dE evdt of this delamrion turnjng our b be eitlEr incmd or anv Pai of this

d<ldi.non subquend\ torMs on ro b+ in(o.'el or f,!P i' '' ddebtmd and aGPbdlhir L\e undedianed rh.llrko b€rldr') epo.Biblebs'ds rhe d<hi' 1r hrG!/he6€UIor anv .uch nbd<laarion or mi$ratmcnt

*,31.1t+Pte (jl;U '

Di A.K, ABOI,I.IHADERFes No 0057 Moas. MD, DICO

Dept. ol Pulmonoloqry(MCT M6dtd Co||€to

Mnr6!dt, (dt*.d.. lcrlb

&-.c","t""ig."a *i\rq;b ty t'"

Di€br/De)l-Piidip€l

1

,'*"" r, r,,. ..".r..tJ+-Dq 3Flrtr A!!e:

Rlt5"1iiY,.'jtiP.cl

"J'ffii"".::,:. ""

,.r":,:lY::,T;::t,iLD!!ei

lsqThe Declarrtiotr Forn dill not be ft.epled rnd rhe pc6on will not be.Dunied as tea.her iranyoliherbovedorumentsxs nor cnclosod/irt!.hedwiththe Dedrr ion liorn.Th. pe6on will nar be.ounted as r tcadrcr if the original of Photo ID pioot Regishationcedi6(ates/ Desree ceniri.rtes / PAN card / sraic Mcdi.al council lD (ir irsued) de notprodu.cd f or verifietion :t th. ti

3. Arl th? rerhcr mui subnit ihe (evis.d de.ianrion lorn in rhis formai o'ny, (Anydela(atio. roln subnited h an old lorn;r rill notberc.epred a

!.]!efr-'.t P*F.n si." pLd. .f tl.c EmPloy&, sjsned by Dern /Pnn Flotlh.rclle*aFioo Io p.or,l i*a uy cu' t ,ldlroLiiis : Pd*6' ' / l'ANcirtl / vobr lDl Aidha.ciklCeiiripd copics ol presert ap!)oi',tmcni orde t Prcs.nt

c+y ot Pasyon /vd{ cdd / El(ti.iLy eill/ lcl.phone Bill

/,\idharCard / Dean'silldn,erilcu.fithchod.s a P60t or

rn\e residen.e.cl,p!.rl """pot'lvd*

c*,1/ ELed'j.irf lrilL/ Ltlcphoie BilL

/ /\iJhrCird attached is aprelol Fad,rn.trt rcsd.n.el(u,is repoird ih. pdd* idru..C.! esor Desre.rdirdrsolMLrbsrll PCdCge9Cur !s or FcFstah! '.1MBB5, rd lrc J-s (ecopy of cxpeien.e cenificaiclorall t.id,irgiPpoinhn.nBh.ld hdore joi'1i.A p'es.nt i'sijiutehh$'n!o',lerton tlcprtq u!i'stiru'ion

F L, L r.Ons.eft'lic:trlior$!h+r ! (.lJ.irL.rer head (in.rseor rea(b€^ wlb.r. p,eti.ins)coD otU.C rd.gnized ter.hcr I

Cofy of l'.G rccognized io.her lekr fro'n aftiLi.iedurivcrcitv.(Ior P.c. A$e$meni)

&v-itied bv the Ai{$or: