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p Harm d Applicationform

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  FORM OF APPLICATION FOR REGITRSTION OF PHARM.D. To,The Registrar,Gujarat State Pharmacy Council,Block – O-4, New Mental Hospital Complex,Asarwa, Ahmedabad – 380016. Sir, 1.Please find enclosed herewith the duly filled in application form for registration u/s32(2) of the Pharmacy Act, 1948.2.A fee of Rs. 500/- as required under State Pharmacy Council Rule is sent byDemand Draft or is paid by cash to the Registrar in person.3.I hereby declare that I have carefully read and understood the instructions and  particulars supplied to me and the information provided by me on the applicationform is true to the best of my knowledge and belief.4.I hereby undertake to follow the rules/regulations/instructions of the Gujarat StatePharmacy Council as issued from time to time.Yours faithfully,Signature Instruction 1.All particulars of the application must be filled in by the applicant in neat legiblehand. Incomplete application will be rejected.2.The name entered in the application must exactly correspond with the name of the applicant entered in the University or other examinations.3.If the space for giving particulars is not found sufficient, a separate sheet may beattached to the application and Page No. of the attached sheet be indicated in themain body of Application Form.  APPLICATION FORM 1.  Name of the Candidate :(Capital words)(Name)(Surname)(as in Degree certificate) 2. Father’s Name:(Capital words)(Name)(Surname) 3. Permanent address:__________________________________  ___________________________________  ___________________________________  __________________________________ Pin code : ________________________  4. Contact Details:STD :________________________ Phone:________________________ Mobile: ________________________ E-mail : ________________________  5. Place & Date of Birth :Place :________________________ D.O.B.:____ / ____ / _____________  6.  Nationality:__________________________________   7. If admission to Pharm.D is on the basis of 10+2 Science academic streamor D.Pharm qualification, please mention details of D.Pharm qualification –    Name of Institution:___________________________  ___________________________   Year of Admission:___________________________   Year of Passing:___________________________    Name of the Examining :___________________________ Authority___________________________  ___________________________  8. In case of Pharm.D. (Post Baccalaureate) please mention details of B.Pharm qualification.   Name of Institution:___________________________  ___________________________   Year of Admission:___________________________   Year of Passing:___________________________    Name of the Examining :___________________________ Authority___________________________  ___________________________   9.Description of Qualification  : Qualification Session of admissionInstitution   Name  ddress  Tel.No.   E-mailHospitalfrom whereinternship isdone   Name  ddress  Tel.No.  E-mail Nameof theExaminingAuthorityYear of  passing Pharm.DPharm.D( Post Baccalaureate) 10.Employment details (if applicable) :Period EmployerNameAddressFromToPresentPrevious
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