Faculty Declaration Form (For AY 2021 - 22) : Remarks and Signature of Assessor
Faculty Declaration Form (For AY 2021 - 22) : Remarks and Signature of Assessor
Faculty Declaration Form (For AY 2021 - 22) : Remarks and Signature of Assessor
______________ _______________
Signature of the Faculty Signature & Seal of Dean
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NMC- Faculty Declaration Form (2021-22)V.1.1
MD/MS
DM/MC
h
PhD
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NMC- Faculty Declaration Form (2021-22)V.1.1
14. Have you been considered in UG/PG, MCI/NMC inspection at any other medical college in
a teaching or administrative capacity during last 3 years. If yes, please give details:
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NMC- Faculty Declaration Form (2021-22)V.1.1
1. April 2020
2. May 2020
3. June 2020
4. July 2020
5. August 2020
6. September 2020
7. October 2020
8. November 2020
9. December 2020
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NMC- Faculty Declaration Form (2021-22)V.1.1
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NMC- Faculty Declaration Form (2021-22)V.1.1
DECLARATION
Date:
Place: ____________________
(Signature of the Faculty)
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NMC- Faculty Declaration Form (2021-22)V.1.1
ENDORSEMENT
1. This endorsement is the certification that the undersigned has satisfied herself/himself
about the correctness, authenticity and veracity of the content of this declaration form in its
entirety and endorsed the above declaration as true and correct. I have personally verified
all the certificates/documents submitted by the teaching faculty with the original
certificates and documents that were submitted by her/him to the Institute and
confirmed the same with the concerned Institute and have found them to be correct
and authentic.
3. In the event of this declaration turning out to be false or incorrect or any part of this
declaration subsequently turning out to be false or incorrect or it comes to light that there
has been suppression of any material information, it is understood and accepted that the
undersigned shall also be equally responsible besides the declarant herself/himself, for the
misdeclaration or misstatement.
Date:
Place: ____________________ ______________________
Signature (Head of Dept.) Signature (Head of Institute)
with official seal with official seal
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NMC- Faculty Declaration Form (2021-22)V.1.1
CHECKLIST
Sl Documents Submitted
1. Recent Passport size photo of Employee, Signed by Dean/Principal of college Yes / No
2. Photo ID proof (Govt. Authority issued): Passport/PAN Card/Voter ID/Aadhar Card Yes / No
3. Certified copy of Appointment order of the present Institute. Yes / No
4. Proof of Residence: Passport/Voter Card/Electricity/Landline phone bill/ Aadhar Card Yes / No
5. Joining report at the present institute. Yes / No
6. Copies of MBBS, PG, PhD degrees (as applicable). Yes / No
7. Copies of MBBS, PG, PhD degree Registration Certificates (as applicable). Yes / No
8. Copy of experience certificates of all teaching appointments before joining present post. Yes / No
9. Relieving order from the previous institution/posting. Yes / No
10. Copy of PAN Card Yes / No
11. Form 16A (downloaded from TRACES) for FY 2019-20 (Assessment Year 2020-21) Yes / No
12. Letter head (in case of teachers who are practicing) Yes / No
13. Copy of letter from affiliating University recognizing as UG teacher Yes / No
14 Copy of letter from affiliating University recognizing as PG teacher (for PG assessment) Yes / No
15 Copy of Aadhar Card Yes / No
_________________ _________________
Signature of Faculty Signature of the HoD.
Date: Date:
________________________ _______________________
Signature of Head of Institute Signed & Verified (Assessor)
Date: Date:
NOTE
I) This Declaration Form will not be accepted and the Faculty member will not be considered as a
Teaching Faculty in case any of the documents listed above are not enclosed/attached with the
Declaration Form.
II) The Faculty member will not be considered as a Teaching Faculty if the original Appointment letter,
Relieving order, Experience certificates, Government Photo ID,Degrees, Registration Certificates,
PAN Card, Aadhar Card, State Medical Council ID (if issued) are not produced for verification at the
time of assessment.
III) Faculty members must submit the revised Declaration form in this format only, Submissions in the
old format will be rejected and Faculty members will not be considered as Teaching Faculty.