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Appendix b

This document is an application form for the registration of pharmacists under the Pharmacy Act, 1948, requiring the applicant to provide personal, educational, and professional details. It includes instructions for completing the application and declarations regarding the applicant's registration status in other states. A registration fee of Rs. 100 is also mentioned, along with the need for a recent passport-sized photograph.

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9 views

Appendix b

This document is an application form for the registration of pharmacists under the Pharmacy Act, 1948, requiring the applicant to provide personal, educational, and professional details. It includes instructions for completing the application and declarations regarding the applicant's registration status in other states. A registration fee of Rs. 100 is also mentioned, along with the need for a recent passport-sized photograph.

Uploaded by

Bimal
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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Rs.

100/-

APPLICATION FORM FOR REGISTRATION OF PHARMACIST


(UNDER SECTION 32(2) OF THE PHARMACY ACT, 1948)
INSTRUCTION
1. All particulars of the application must be filled in by the applicant in neat legible hand. Incomplete application
will be rejected.
2. The name entered in the application must exactly correspond with the name of the application entered in the
University or other examinations.
3. If the space for giving particulars is not found sufficient, a separate sheet may be attached to the application
and page No.-of the attached sheet be indicated in the main body of Application From.

To,
The Registrar,
Affix recent self
Uttarakhand Pharmacy Council, attested
Dehradun. passport size
Sub: Registration as a Pharmacist under the Pharmacy Act, 1948. photograph
Ref: Your Letter No. ………………………. Dated…………………..
Sir/Madam,
1. Please find enclosed herewith the duly filled in application form for registration u/s12(2) of the Pharmacy Act,
1948.
2. D.D.No./Online Payment No………………………………….. dated……………. For Rs. ……… is enclosed
herewith as a resgistration fee for the purpose.
3. I hereby declare that I have carefully read and understood the instruction and particulars supplied to me and
the information provided by me on the application form is true to the best of my knowledge and belief.
4. I hereby undertake to follow the rules/regulation/instruction of the Uttarakhand State Pharmacy Council as
issued from time to time.

Yours faithfully

Name of Applicant
Signature
APPLICATION FORM

1. Applicant’s Name in Full (as in Degree Certificate)

2. Date, Month and Year of Birth

3. Father’s/Husband’s Name (Full in Capital Letter)

4. Full (Permanent) Residential Address (In Capital Letter) …………………………………………………………...


………………………………………………………………………………………………………………………………
5. Full Professional Address …………………………….…………………………………………...…………………….
………………………………………………………………………………………………………………………………
6. Nationality …………………………………… Place of Birth …………….………………………………...…………..
7. Telephone/Mobile No. …………………………………………………… E-Mail Address …………..………………
8. If admission to PharmD. Is on the basis of D.Pharm qualification, please mention details of D.Pharm
qualification-
Name of Institution Year of admission Year of passing Name of the Examining Authority

9. 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

10. Description of qualification-


Qualification Session of Institute Hospital from where Name of the Year of
Admission • Name internship is done Examining Passing
• Address • Name Authority
• Mobile No. • Address
• E-Mail • Mobile No.
• Email

Pharm.D

Pharm .D
(Post
Baccalaureate)
11. Employment details (if applicable):

Employer Name Address Period


From To

12. Declarations:
• I hereby declare that I have not so far registered my name in any other State Pharmacy Council in India. This
is my first application made with required enclosure for registration in this State as a Pharmacist.
• I hereby declare that prior to this application I had registered my name in the State/s as details below from
time (eligible/not eligible).
Name of State Qualification Reg.No. Date Duration
From To
Ist Registration
Ist Re- Registration
IInd Re- Registration
IIIrd Re-Registration
IVth Re- Registration

• I hereby declare that I desire to take up the practice of the profession of Pharmacy in State of
…………………….. by residing in this State. Hence this application is made for registration/re-registration in
the ……………… State Pharmacy Council.
• I hereby declare that information given in the application from is true and In understand that my application is
liable to be rejected summarily or the registration is liable to be cancelled forthwith, u/s 36 of the Pharmacy
Act 1948 if the above information is proved to be false in any particular, at any stage.
• Any other information by the applicant.

Please strike whichever is not applicable


Date………….

(Signature of Applicant)

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