NAME OF THE COLLEGE I^l

AUrtt

DEcLARATIoN FoRM : zore-ts - RESIDENT SNYJR{Nok : rrn csPonsibili9 of Deiq

dhd onese duinB &ademi. y€r md wo*in* rs fult dne)

""."...br..... i{.linru.'... .N. A (.R... .......

iiTfll iKJll,"d:"1:'s: lillillti,*;, .:! N( crYi...:arr. Air:7.

Nore r, wi,hdr phob tD. Dedrnion ro,n si be rejeftd rd wi 1or be.onjdp,"d:\!"llc ffurry. 2\ orisinrr (eni{i,rre. Le mJndrory for \crificrior Altcsiifi.arer,Docunentycerifie<tTresl'rione, mu*be in EnEIish

r.-.*o".,g, "no. {i ,.,.- ,le',i\i

D4ts o dopda :i7n | &i vlr - r'lru .- o*,,r*-" dr,Lrr, *r",.one3e /. ea r Mr 4wheth.r appJnje.l and ac.epred id bst Mcl UG/!c Asssne.r in dre same

wherhe! appcarelr and a.cpied in rnn Mcr uc/I]c Awenr on sane

c:mpus/ Pread ad,lr.s

LM).

D" eolr'h t' Ase )Llc:ltq'v...\'..1srbnrPhoio rD ploof isu?d by covi. Audroriti6:

N,t n

-. :L&E,uPwu5bopolDcu

1.(t

Pemddt Addrs oI R6iddL\!,1+L-&zt1l

&r.h.r €0,1,), t\vyd^Jrr%zc ?o i-ln,t1(rBt(€Q &.A

copyof p@on Aj,ohsnr Leh.rand p.mrn.!t residen,iar ddre$ pmf ,*.h.aytN..

i {8) conL I n ticut,c. rel,oltr,: D_!:L5:-L55e1_lv,,hsm.odetrs{rardene): aeLrq )4 i5 -l: {wiifr sTD c@;J

f,ml{i,;r ft) DakorpninsPrqtGdtotion i

r.0 loinins €rDd d the pl*n,,*,o*",o.n* - Vi^.

\de ror Fcfolr fc gudrx (rtorudd,riotut tu36bdb@ prto (ahpdo, uldE bF fuuh"d andli:': ' 5_l'j1:f* :.*_ 0,5*6 dEr\.ymso, qtucrNe s norappr,(abh..8

' r opreeor Deglee.enificb ofMBBSand pc d€sree ahJ!hed: y.jato

2.(bJ Copie, of Regiftaiion ot MBBS.nd pc degree ara.hed yeqpta

trt*^Ae"irr"lL&\etL-

(e:+. {h,.lLed.uJtdl€tr

&A !'1 6 ).'aot LqLqb 1 L r'1 O

Deians ol l1E baching expenence rilt dare.

.r.(a) B.foe joinins presenr iBritution I ws woi*ins d il ar n.!{l\ \$\$aL 61 ..--=l. t+.l!J..l,r "'d '.r*"d o, 1L:oreienins /rrmtednS /Gelievi{, ord€r is enctosed I6n rhe previous in*irltion).

5. I hav€ d rapn iotn siipend fron rhis college in Lhe cur€nr limn ir I year as under.

**.ry2" trzx '&s,;l""t -*,ing rhar r an a Fuu tinc Re8'nar Reidenr in

;nd am rayins in Room N; / 7 4 m dre

2. Fu hcr,Idare ihai Iam notdoing any Pivare pradi.e ornor working in anyotherhcpihl

3. I have not work€d at any obher medical .ollqe/iNiitlrion o. prs.nted nysell ai anyA]'g.mer l rhr!umnr {ddan jcd

I MCi' 'i, tL 11,il,

Ir \ da!'ed hJr e4n,nh n4r d d o, on,erb of U b dctd,dr,o,n" dtrdzhon rc,m. b) *e rd45SnFd rp dbetubty

dL h-nh rn L\p sFnr o. dn) n",emenr r$r; L\,. datrahm5u6.9unuv to' rrg our btf de un,lq ,sn.d \n. rrdeFb@ Jd4 poled ur.i .'!h mbd(t"aLjo i,n F-p4r br \ lonFn, o, rlbopdddtioa 5 b rt.o b€TA.ondu!. t\p,.by F.da.n8 dr Lnd"\,snrd dbtF ro G>d^os,ptrn4r),i bon lrT,Jn s,"r r.,t o, r,. n4m",.or,.ddn M;dr,t Rer.Fri

ENDORSEMENT

5 rh",e,a,.r.or rhdr rhe udq5.dnql hd. DJdJ eJ hm-t /h"ptl

5uDnrned by rhe\.ndidnc wirh rhco,rginj t enif.\ rtsv ddua.nh J. \ubfrded b! rhenh rhp (onre-ned in,r,rure {nd hrt. roLnd rhen b bc

n horlin8 Js fr bnc Resutdof carrying out any other a.tiviy dd isHostel in.ouege premis, since he/she

h- lnp f\{. d Jrb d* a,.,rci tumj, g or rc 4 erJs 1on4 , ., r1y prn o. bbodrdrlmsub-.qFdj) rL'rng ou' b bD ircon^ r., tahe ir i. undc\Eod rd d(eDkdr4 h" mdea'sr{ $dltdt{ b- "qu"rty F\ponqbt. @.dh r}" o(tu r h,tu"4 r;curcran' 5d.h mFdrbdtion or hi$taremenr

,. (->_

counieGi8led wjih srafp by rheDnebr/Dcan/Pdncipal

,,^.^*,w,,".^,,D!!!i

sined bv the Hop:Sd!l

eq!!L-,"r*d.,,,i.*,';rb";".,J;',:F,,J.S4!l

sioed & Veri6€d bv the Assesoi :

3. AI .fie Regidenr nusi subnir rhe rdised detararion form in .hi3rLdaation fom subnifted in m old fornar wilt not be a..epted..d he

NOTE:1. Th" De.td.rion iom will nat be e(epral-dd rhe pe*on wi nor be tosred re Re\idenr i(dt oflherbovpdotunenbre rct €nlto\edl,tleh.d w h rhe D€ltrJrion lornz The ?_4$n Mll rct be ouded as a Resid€nr if th€ onsin t of photo rD prco, R%i*{ioncrdifildA/ Degre,edinote. / pAN card / Mcr imd rDcrdAla; M.djic@n.il

,ut r ^\!ed

j end prcdu(ed forvcnfication.ttlerjneot.s!e.rn€nt,

RRni PdsPod si? Photoor &e olqe.ftobID pmt$rd by ovr Aurho'ir6 p6Fa co;7pa\ (a,d/ Vorer lD / Aadhar c,rd

..p!q4]!sjl!kErqqg!&rrcd d pft,,rr B d.Ift."-.54 ("J coPy oI PssPon /vohr Grd / Ekrjcity

4adtBcard db:hed 6 a pmr orpemdsi

copi6 or p.sre cdncab or MBBS J rrc;G;gopi6!rResfbabon or MBBSand rc desreLopy oi e\p€hence cerhh.aF ror aII rpDoinlmenb hetde6enr iretiture.Kexevmg otuer kom beprcvious iEritudon.copy or Aadhar caid

\.-

NAME OF THE COLLEGE: kn1c-I MGDI.4I (OLT+I,G I.JO5'I',A

r!1.i11"'":1r,9.1

DECLARATION FORM : 201S.19 - RESIDENT (iR/JR)(\-ok I nLEsPonsibjrfty orD..n

!indworrinssn,rr tino

^!rEq!!r l H.1. .rc )r L 8f1.4 g)

\t\e,lIqsq. ...lz,Ur'!"r t) suL,nrir i,horo rD prsr kn,.r br cN'

^u[bnrj$PhololDsubjnihed:,2P6sporr copy / PANj"?d / vd4 rrrl^rdha! c,d.

N".1., .... .gj,l9lJ.6.5 5t6- k--i r,lNd.: 1) rljrhod Phdo rD, D&hGtn,n r..n wi be rcjcdcd d sirlrca.hinE rm,hy. 2) o.ieimr c.*ifi.{es are mrnd oryccitifi .der,Do.uneiit/i]efr if ieJ r'dn.radon., nun be in Engrish

:(i) i. rlG.nr rrsirqniriorl scNroQ casro6Nr

' Nrlr Lru/Rr/ \nr o[ er \$.s rsi

44L, !.!qf e6sro6d5- 4vaer6d,l.rsd^se5ey ?o I r1!-L^at v o24t.oo6

*;,ifffi''**"

-!F^^,el'"r _t'"\firo\(,^! "*-,"$*tdl;;;"d ",

nh.rrrar :I)teatud .n .t(rftutl

$h.rh$ .\it..nd .id {(?trll ,i r.rr ll.r - Lra

Pernaftnt Addrs of R6'ddli

tctad

copyotR@nArrob. rt!h'rndP€tui.1t16rielti.t-ildlsPMf dth'd.Y6/N';;;;;;; r"iron;.ul

- ot q< eaq gso"D..llo (wrth srD.ode)

Enailadd6 a$'4a&!

1.O) D6k oI joini4 plent inshtltio:1.(tz

Joinjng repon at the prsnt irehbE abchd

Na;-E;ffiafr st;ltcafifuA;iond R%i"hhd cdtitkab Particulds tt ru.nished and

slbr{r be fumGried wjlhin btureb afbr sring od whichever is nor aPPli6ble;i;;- i;;r;;;;;;;..t6 or MBBs:"d Pc deg*.ft..hJ - l"eqN"

2.(b) copi€r of R€gist.tion of MBBS.nd PG degree ad.ched YetN6

MSBS

Rc,u\ls

ea) oale

9or\t 5J{ Rlt,lr s

rhP rPa$i'rc erperidd.e brr nik

a.l o 6l E

oclo. Lr( z-o)orlrr

U^;""prcscir i,$iiiuhr r r qa! !,, rl n! ir

Eisn,ns / liaNreri'rB /(Relievins

I havedrawn bbr{il*arfrom ihr

lt;;''o-

S^-i.,l, e,,|.'t,",tr,,,r,.

,,m ,, [1,[ ri,n. R$trrir R!5 edr iin.,rir[ i] RqD \o ql.t 4 r n

a..,J.,i rr.r.r{ rr r|,rr f n\11 fr.ldi.!..'

I

3tr n n"tJ L"tr,4-".

",r*--r- ellLlr?o.der isen.loscd frcmthe previous in{itution)

colcgc in iric.uiienrf i .nriar ]edrd5 uo(rer

J1919{

r. n. irgah n( orqj. ., ro !.,.b1; $,\c ,nl

d/or.ontenc o, rhk d{hnrion inJ /or nt{unnrts...lhf.irs srbmittcJ iong \!th thc dNlariior n\rn, b) thc u&lcFignd ir. ila.rutlv

n'bsqucnrly trtrni'rg out ro b. iNo,rcd o. rakc th. unn.Eigncd his undc6rooJ indk.pred rhl su.h Dndalri;ii.'r ir r.sFe.r roady...tu.r of rhnt at.J rs a grcs misondud th.reb), renllering the und.'sign.J liitrlc fd n((siry

tr,\*lro

R.s .nt (i... ror 2r hou,t ind is not pricii.ins or cining otrt ior oihcr i.hui\slrriit Roon No JJa {nd'eRd edrt Flo*eljd colleF prui'i*, iin.e

Iararion ttrmi.g out b b. eirher i'roii{r .I any p€{ oI ihisd{larahon s'bsquently toming our to be incor{i or lale it is rnderioJ J a..cphdthdiheundersgnd shallal$ be uilly rcspons,bietts 6ih.d(l.ninrhimseLr/herselt

corrteBisned siihdamp b rheDlRiu/ r)e,rr(Prha P.il

,,,"i'l[i'tK*"*

FNoosti M Jc*r^nhp,

Thh end.fenenr n t[d .enili.:tid' rh* 0'd u d6iljidd hrs srhrial hi'nsell /her+llnbour ihc .atr€tncs inl vcra.itl 01 crch coit.nr of rhk dNhrrtiof rnd cndor{s thcibolem.niionRl ddrrihon as tL'c rnd .orNt I hrvc vc.ified thc.dtifi.rtes/do.!frenssubnitr€d by rhec didai€ siih th€ disinal ertilicd€t d(umen

sti $ Jc*r^nhp) ,. \.orri

f.r ys(h nisredaidi,r d mns6'!{ndt'

Dd. iltlosl"w gV.q>nr": fl&"{4!Bd

"st

Rdlrit rasport slze ph.to of ih. Lmployee Siroed by Deai / Pri'ri$l

rhob ID pi6l isn'e.l bt covt. Authoritres: Pi$l{)*coP| / PAN crrtl

I cn cdlopc, lp'e.err I prc'.nr tr iL e

t\ DPr, , p.o I,copy ot l'a$lDi /vot.r cird / Elrti.ilv Bill / relephone Bill /\JJhd.dJ rL. tr,ld d p.mlo

5

Copi.6 or Reqnbrdi or lllBBs an.l I\] deeR.cop| ol.ip.icn.. ..difi.at for ill ipF.inrneib held befor€ joi'inrq

3.lkInr((rsrr\m rrE pre\ ou. i'Erturon

qr!!! ' S!!r

t be r(cpted rnd the Pe4on willanvof the,bove documenbare notendos.d/atxhed wnhthe D(l'ration Form

2 Ih€peenwillndb€.ornredasaResidcntifrncarisinrlor Phoro ID pioot Regiir:rionc€diri.ates/ Desre.ediri.ar€s / PAN card / Mcl smat ll)ctdftate Medkal coun.illDi if issued J aF nortrodu.ed ro

3. AI th€ llesident rion form in this formar only (Anydedar.tionfom subniftd inan nd heaill nor h..ounr€d

NAME OF THE COLLEGE coLLEztE . tJtMeteLl

DEGLARATTON FORM ! 2Ota.l9

.....?! / e9/.t p.?-..,. . 2r....

- RESIDENT SXUJRlNak. Ir iseeoE,htrr), of Dru4 soD & re5id;.,h".."rre8. d*,.s.."d..r.,.*""d

"";ir"s";rlar N:mc.. . RA4UL B4'r-.4ra6..4NaN

I {b) D"h o, 8trth & ACe

(") il:il$ixt#JJ:'*".d by covL Auirroriiis l

mH jg'1;:)iii,i1&t:j:/::li:# b r.l$r69ts..lDEl\(tft (.fi eN ft1r?Dr,rtl

oF tiD

t^'

Nde jr w.rhour pn ro rD. Orltr.d,on (o,D H,tj be j-ided rd w, nd be lonvde.ed 15F,onC, n r4rulry, -2r .O,,gir.t aeni.i.de.

\ cmi,., eq,uo.umentrcedTjcd rrd.t:hon.. nur bein rndi.h

1.(d)vii

PleentDesis.ahonr :IrNina K€<rpENr

D+{h q AryllJl4g4Aj_College: y'r 6 vgnl.tt- 0)1186 . ruruaqJzg

uclrc/tuj o$er As65m€nr _,n \htrh

iff*-"igf"j " ' *"" ' L" M.' - uc rc a. Nm"n D ,,. \.rp

H;T"liItiI.'.'"J "p'l{ 'LJ'|v' uc !A*om"i n$'cimPus / PrAfltaddres or Reden!l99O tzESDeNf

\Seryrs (d{\itJ PlrtuN'ha l-l

r.(d conb.trarh.urd6: Tel/O |-) _ (wirj <mrcdq

Ma'reNtntff 97a.3oo

Y.4N.JuP-(p<r) kEa4) - b+ozott

oof dk.hed. Y*/No.

1.(h) Dare orjoinins presenr iBrx[i,6: ftlia/b as ^)utvL

pztlpeilr

1.(i) hinins ppod d the pist iddnrte anached , Yer/Ne

Noh: For ?G?os PC qualifi.aiioh additioMl Re8isbadon cdfi.aE parti.ula6 b. lurnished edsubjd be fumished widrin bFckeb atter scoring our whichever is nor appli.able2(a) Copies ol De8ree ceni fi.its of M BB s and Pc dqrcc rtmhed - Yetol!2.(l ) copi* of R€giskatton or MBBS and rc degree aniched Ye*oJa

59t z3 lUnL

DDAIM .y r\pe,ien.e

Details ot the iea.hing expeio.e h date

4.G l Selorcronn8 p6cnr Ghtution I w"s

reisnns /TraNlerrins /(Rerievins or.ler is enclosed fron th€ prenous rnnndiol.I have dra* n iotal *ipend tbn rhis .o ege in n\c curent tiDncjal year as under.

DECLARATION

ndd!!.a8 rhd dn d tL mc pegtl_r RerdFnr in

,ffi; **"nlie;l* d 'd

,r sb\ ns 'n

R@m \o ,oo . dr"

F trl}", I nah ha t.T' d Jo;s "1. fr r, ts p,i, n p o. ro, -o.r,n8,n d \ orT. | 6p,.dl

J re" rcr !o,l"d r:N ob- r^oh4 !o.."C". T!tution o, pPcn-d m\\etr r r)

4. lt is delaed ihrr pach sbremenr md/or conienr. of 0 . d<laration and /or demenb,cedifi.ae subniftd alonS with the d(laration fora by ihe mde$ismd are abs.rnFly

In in€ 4ent of zny sritsn4t made in this d*lahtionsubsequenrly turnin3 our ro b€ incorKt or lalsc Lhe undeBisn€d has undeBrmd andac.epbd tnat such nisddaration in r€sp{t b &y .ontent of thb delaration shall aho bekared s a aro$ misondud thereby ftndering the mdersigrud liabls lor nffisarydnciplinary acdon (i.cluding renoval ot his nane frofr Indian Medicat ReSisb.r.

'@!'SICNATURE OT THE RESIDENT

ENDORSEMENT

Counte6iSned with st mp by rheDt{bilDean/Piin.ipal

Inis endoRnenr ir the @iiificaiion that Llre udersiFed has saddied him$lJ /heelfabout rhe corKh6s md vera.ity ot ea.h conbt ot this d4laration and end66 tncahovementioned dclaration as hue and.orer. I hav€ verified the c€dificarey do.unenbgubnited by the cmdidat€ wnn tie di8inal edificaks/ documenh as subnitt.d by rheReetdent to the inetihre and with the .on emed in*iirb and have fornd rhen ro b€.orect and authenn.,

I aLo snfim b\at Dr. R ru! zlMaBErellNAJ h working 6 tln dme R€gularR6idenr (i.€. Ior 2,t ho!6) and is nor pracb.ins or carrying out my orher a.rivfty and issbying in Room No. 2.rs ol ine Reidenb Hcter in colleSe prenis6,3in.e he/she

In the €vent of thn ddaraiion turniry our io be eider imorcr oi any pnrr ot L\ndRlraiion sub*ruendy tuhing out to be in.onEr or tals€ it is undersiod and accepddDt dp undersigned shall dso b€ e,tually r6po6ible b€sid6 the delaranr himser/heMufor any such nisdelaration or mnshbnaL

-,'e+c'-

Rerent PasIDn sia phob ot rhe Employcc Signed by Dea. / Pln.ipal

Phot ID proofisued trycovr. auth.iries Pa$poicopy / PANcarJf Yot.rlD/

^adharcrrd/C_r f ed spre o'p1 enr dpp' rel. odcf d pm.o' 1.'ru'ecopy ol Anoiment L.ftr by Dean as pioolofpresenr rcsidcn.e adore$copy ot Pa$poir /vote! cad / El(rhity Biu / retephonc BiI /addh: .r'd{nr \pd., dp,ooro prm , ii 1" ,'dpnt " ddd cloininB repod ar rhc prcscni nq IrecoPrcs ol DeSre lerrira!\ arMcopi6of RegFhahonof MBssand rE desrlr.copy of exp€rience.edin.ah for all apponnmenb hetd b€fore JoininS

R€iievnrg ordei f.oh the previous iretfiurioncopr or4JdhJrci

siSnrd & veriried bv the a$essor :

PsE r

\sqThe Declaration Forn will not be ac.epied and rhe pe4on will not be counrcd as Residenr ifan! of the abore docuncnrs re not endosed / att&hed wirh rhe D€dxarion Iorn.The pe6on will not be.ounted as a Residenr if ihe original of Phoro ID Foor, Resinrafionccnifi.aies/ Desre .etifi.ates / PAN cad / McI snd ID cardlsraie Medical coun.ilrD { ir issued ) are not plodu.ed for vcrific ionaiiheiiheotassessneniAll ihe nesident nu* subnit rhe rNised dedaiation fom in ihis fornat onrv. {Anvde(l rtion form \ubni{cd,n Jn old ro'md w:llnor be i<eored 4nd h" wittnd #.ounr;

Sdli