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ApplicationForm UPPC

The document is an application form for registration as a pharmacist with the Uttar Pradesh Pharmacy Council. It requests personal details, education and qualification details, internship details, and requires uploading of documents like marksheets, certificates and identification proofs.

Uploaded by

hemant
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38 views

ApplicationForm UPPC

The document is an application form for registration as a pharmacist with the Uttar Pradesh Pharmacy Council. It requests personal details, education and qualification details, internship details, and requires uploading of documents like marksheets, certificates and identification proofs.

Uploaded by

hemant
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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U.P.

Pharmacy Council
Lekhraj Market-2, II floor, Indira Nagar, Lucknow
Application Form for Pharmacist's Registration
Applicant No.
Applicant Name Gender
Date of Birth Place of Birth
Father's Name Category
Religion Aadhar No.
Mobile No. EmailId
Permanent Address
House No. Village/Locality
PS (Police Station) District
State Country
PIN Code Nationality
Correspondence Address
House No. Village/Locality
PS (Police Station) District
State Country
PIN Code Nationality
Description of Education Qualification

Examining Body Name of Course Started Course Ended Maximum Obtained Secured
Qualification CGPA
Name Institution in Year in Year Marks Marks (%)
High School
Intermediate
D. Pharma

Address of Institute From last Education Qualification Acquired


Roll No. Degree Name
Address District
State PIN Code
Internship Details
Hospital / Organization Name
Address District
Internship Period (From) Internship Period (Till)
Uploaded Documents

Photograph Signature

High School Marksheet Upload

High School Certificate Upload

Intermediate Marksheet Upload

Intermediate Certificate Upload

D.Pharma/B.Pharma/M.Pharma/Doctor of Pharmacy Marksheet Upload

D.Pharma/B.Pharma/M.Pharma/Doctor of Pharmacy Certificate Upload

Internship Certificate (In Case of D.Pharma) Upload

Domicile of UP Certificate (Issued Within 6 Months) Upload

Scanned copy of valid ID proof (Aadhaar Card/ Voter ID / Residence Certificate) Upload

PCI College Approval U/S-12 Upload

Affidavit Upload
Declaration
I hereby declare that all the information submitted by me in this application form is correct, true and valid. If any ambiguity in the
certificates produced by me is noticed, my registration will be canceled automatically with immediate effect and the council will be
completely free to take action, for which I myself will be responsible.
Printed Date :

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