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Form - 'G'
FORM OF APPLICATION FOR TRANSFER BASES REGISTRATION AS A PHARMACIST
UNDER SECTION 32(2) OF THE PHARMACY ACT, 1948
Applicant’s Name (As per registration certificate)
*
Date of Birth
*
MM slash DD slash YYYY
Father’s/Husband’s Name
*
Full (Permanent) Residential Address
*
Full Temporary/Professional Work Address
*
Nationality
*
Religion
*
Telephone/Mobile No
*
E-Mail Address
*
Domicile if the Indian domicile has been acquired recently, Sate when and where it was acquired
Aadhar Number
*
If you are not Indian National, does country where you acquired by qualification permit persons of Indian origin possessing qualification of that country to enter and practice the profession of Pharmacy there, if so, quote section or rule under which this is permitted in that country
Qualification Description for which registration is required
High School
Year
Name of Examining Body which awarded
Name of College/Institution
Commenced on Date/Year
Ended on dated/Year
Intermediate
Year
Name of Examining Body which awarded
Name of College/Institution
Commenced on Date/Year
Ended on dated/Year
D.Pharm
Year
Name of Examining Body which awarded
Name of College/Institution
Commenced on Date/Year
Ended on dated/Year
B.Pharm
Year
Name of Examining Body which awarded
Name of College/Institution
Commenced on Date/Year
Ended on dated/Year
M.Pharm
Year
Name of Examining Body which awarded
Name of College/Institution
Commenced on Date/Year
Ended on dated/Year
Pharm D
Year
Name of Examining Body which awarded
Name of College/Institution
Commenced on Date/Year
Ended on dated/Year
Registered in State Pharmacy Council
Name of State Pharmacy Council
*
Registration Number
*
Date
*
MM slash DD slash YYYY
Under Section of the Pharmacy Act.
*
Employment Details
Date from which practicing in Uttarakhand
MM slash DD slash YYYY
Whether employed in or attached to Government or State aided institution, if so State is name address and the date from which employed
Basic Qualification (Educational) before joining the training of Pharmacy
Documents need to be upload
(max size-1MB file types-pdf, jpg, docx)
Domicile (if available)
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Aadhar Card (mandatory)
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
High school marksheet & passing certificate
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Intermediate marksheet & passing certificate
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Diploma / Degree (all year marksheet)
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Diploma / Degree
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Photograph
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Specimen signature
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Fee receipt (UPI/UTR/Transaction/Account No)
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Reg. Certificate (valid) & Update Renewal Certificate (valid)
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
500 hr. training certificate
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Affidavit
*
Accepted file types: jpg, pdf, docx, Max. file size: 1 MB.
Note: At the time of verification of original documents in the council office, also submit the original copy of your Pharmacist registration certificate, valid renewal card and affidavit along with 2 A4 size envelopes with pasted speed post stamp (current charges) and 1 Passport size photo.
(नोट: काउन्सिल कार्यालय में मूल दस्तावेजों के सत्यापन के समय अपने फार्मेसिस्ट पंजीकरण प्रमाण पत्र, वैध रिन्यूअल कार्ड की मूल प्रति एवं शपथ पत्र के साथ दो A4 साइज के स्पीड पोस्ट (मूल्य के बराबर) टिकट लगे हुए लिफाफे व 1 पासपोर्ट साइज़ फोटो भी जमा करायें ।)
Note: Please take a prior appointment with the Council before visiting the office to submit all documents.
(नोट: काउन्सिल से अनुमति लेने के पश्चात् ही मूल दस्तावेजों के सत्यापन के लिए काउन्सिल में उपस्थित हों ।)
Online Fee Rs. 2000
Note: Along with the registration fee Rs. 500, submit Rs 100 for the form fee.
(कृपया रजिस्ट्रेशन फीस 500 के साथ 100 रूपये फॉर्म फीस भी जमा करें !)
For online payment -
Account Holder - Uttarakhand Pharmacy Council
Bank - State Bank of India
A/c No. - 36821630863
IFSC - SBIN007893
*
I hereby confirm that the above information is correct. I undertake to provide the originals of any of the documents mentioned above should they be required by UKPC. I accept that UKPC Rules and Regulations stipulated here may be subject to change.
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