KSPC - A - Karnataka State Pharmacy Council

KSPC - A
KARNATAKA STATE PHARMACY COUNCIL
514/E, I Main, II Stage, Vijayanagar, Bangalore – 560 104
Ph: 080-23404000, 23383142, Mob: 9900032640
E-mail: [email protected], Web: www.kspcdic.com
FORM G
(See Rule 48)
APPLICATION FOR FRESH REGISTRATION OF PHARMACIST
(Under the Pharmacy Act, 1948)
To,
The Registrar
Karnataka State Pharmacy Council
Bangalore - 560 104
Sir,
I, hereby request you to register my name on the rolls of Karnataka State Pharmacy Council as a Registered
Pharmacist and issue the Registered Pharmacist Certificate under the Pharmacy Act, 1948. I furnish the
requisite particulars hereunder:
Name of the applicant in
BLOCK letters
Smt / Shri:
College ID / Employment
ID if any
Name of the Father
Shri:
Name of the Mother
Smt:
Name of the Spouse
(Husband/Wife)
Shri / Smt:
Age, Date & Place of
birth
Age: ……………………..
Date of birth: …………………………...…
Blood Group:
Nationality: ______________
…………………
Place of birth: ………………………….…..
(Enclose copy of passport and
VISA in case you are not an
Indian national)
Proof of date of birth
SSLC / X std / TC / Cumulative record / Birth Certificate (Tick the appropriate one)
Residential address in
Karnataka where you are
staying or intend to stay
DISTRICT: ………………………………
PIN:……………………...
Permanent Residential
Address
DISTRICT: ……………………………… PIN:……………………... STATE:…………………………..………………
Name and contact No of
the land lord, if residing
in a rented building (FOR
STUDENTS ONLY)
DISTRICT: ………………………………
Name and Contact No of
the warden, in case
college hostel address is
given
PIN:……………………...
Name: …………………………………………………………………………….. Ph. No: …………………………………
Designation: …………………………………………………
ADD:
Your office address in
Karnataka state
Name of the employer / partner / any
responsible person in office:
CITY:
Contact No:
PIN:
Present contact details
E-mail id:
Mobile No:
Land line No:
Alternate contacts
Name:
Mobile No:
E-mail id:
Land line No:
Qualification to be registered
Qualification
Name of the College & Place
Name of the Board /
University
Year of
passing
PCI approval
letter Ref No.
D Pharm
B Pharm
M. Pharm
PharmD
List of enclosures:
Sl.No.
Particulars
1.
Proof of date of birth: SSLC Marks Card / X std / Transfer Certificate / Cumulative
Record / Birth Certificate – Original with one A4 Size Xerox Copy.
Marks Card: Second PUC - in original with one A4 Size Xerox Copy
Marks card: First and final year - all in original with one A4 Size Xerox Copy.
Pharmacy qualification certificate: D. Pharm / B. Pharm / M. Pharm / PharmD. - all
in original with one A4 Size Xerox Copy.
Proof of Address in Karnataka: Copy of any document with photograph issued by
Govt / Quasi Govt., OR original letter with photo affixed issued by the employer not
prior to six months from the date of this application should be submitted.
Recent passport size colour photos (2 Nos.) Please write the name of the candidate
on the back of the photos.
Blood Group report issued by a pathology laboratory / hospital.
PCI letter showing the approval status of the college for the period of study.
Affidavit as per format, in case Registration is delayed beyond 12 months from date of
receipt of diploma / degree certificate.
2.
3.
4.
5.
6.
7.
8.
9.
Original
Yes/No
Copy
Yes/No
Details of Fees remitted (Fee once paid is non-refundable):
DD in
favour of
Amount
KSPC
Rs. 1,150/-
KRPWT
Rs. 2,500/-
Demand
draft No
Date
Name of the bank
Receipt No / date
(To be entered by the
office)
Declaration
1. I hereby declare that I have not applied for registration or registered my name in any of the
state pharmacy councils in India and this is my first application for fresh registration at this
council.
Passport photo
2. I hereby declare that I intend to stay and practice profession of pharmacy in the Karnataka
state.
3. I hereby affirm and declare that the information furnished above is true and correct to the best
of my knowledge and belief. I also understand that incomplete application is liable to be rejected
and any deficiency is to be made-up within 3 months. I am liable for disciplinary action in case the
above information are found to be false and incorrect.
4. I understand that the Registrar reserves the right
document/s to satisfy himself on the eligibility for registration.
Place:
Date:
to
call
for
any
additional
Signature of the applicant
Specimen Signature of the Applicant
1. …………………………………………………………….…..
2. ………………………………………..…..……………. 3. ……………………………………………………………..
AFFIDAVIT
(For those who have failed to register within one year of their diploma/degree)
I Sri / Smt………………………..S/o / D/o Sri………………………………… aged………….years
residing at
……………………………………………………………………… do hereby solemnly affirm and state as under:
1. That I am a D. Pharm / B.Pharm / M. Pharm / Pharm D graduate from the
……………………………………………
(college)
under………………………………………
(Board / University).
2. The period of my studies are as under:
Courses
Period of study
Year of passing
D. Pharm
………… to ……………..
……………………………
B.Pharm
………… to ……………..
……………………………
M. Pharm
………….to………………
…………………….……..
Pharm D
………… to ……………..
…………………………....
3. Now I intend to register my name in the Karnataka State Pharmacy Council and seek a
‘Registered Pharmacist’ certificate’ and Id. Card.
4. I declare hereby that I have not registered my name in any other state council in India.
5. I intend to stay and practice pharmacy in Karnataka state.
6. I swear that the information furnished above are true and correct and I hereby absolve the
Karnataka State Pharmacy Council and its staff from all responsibilities with the issue of the
‘Registered Pharmacists Certificate’ to me, which I affirm is done on the basis of my claims
and this affidavit sworn by me.
Witness
Deponent candidate
Signature:
Date:
Name:
Address:
KARNATAKA REGISTERED PHARMACISTS WELFARE TRUST
RULES 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.
KRPWT - A
KARNATAKA REGISTERED PHARMACISTS WELFARE TRUST (Reg.)
Vijayanagar, Bangalore - 560 040
APPLICATION FORM
(Fill in block letters only)
1.
NAME OF THE APPLICANT
(As appears in the registration certificate)
2.
KSPC REGISTRATION NUMBER
(enclose a copy of the certificate)
3.
FATHER’S NAME
4.
SPOUSE NAME (Husband / Wife)
5.
SEX (Tick the appropriate one)
6.
AGE / DATE OF BIRTH
7.
BLOOD GROUP
8.
ADDRESS (permanent)
9.
PREFERRED MAILING ADDRESS
MALE / FEMALE
…....... yrs
10.
DOB : ……………………………..
NAME OF THE NOMINEE
11.
Signature of the
the Nominee: 1)
……………………………………………………………..…..…………………...
2)
…………………………………………………………………….…………..……..
PHOTO
(Affix Passport Photo
here)
12.
AGE & DATE OF BIRTH OF THE NOMINEE
……….. yrs
13.
RELATIONSHIP TO THE APPLICANT
14.
IN CASE OF MINOR, PLEASE MENTION
GUARDIAN’S NAME
15.
ADDRESS OF THE NOMINEE
16.
MODE OF PAYMENT Tick the appropriate one and
fill the details)
DOB: ……………………………..
DD / PAY ORDER NO: ………………………………………… DD. Date: ………….…………………………
BANK: ………………………………………………………………………………. PLACE: ……………………………
Note : DD/Pay Order of Rs.2,500/- to be sent in favour of Karnataka Registered Pharmacist Welfare Trust,
payable at Bangalore
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
-----------------------------------------------------------------------------------------------------------------------------------------------For office use only
Verification remark by office:
Receipt No. & Date: ……………………..
MANAGING TRUSTEE
Enrollment No. & Date: …………………………….