KARNATAKA STATE PHARMACY COUNCIL

No. 514/E, 1 Main, Vijayanagar Club Road, R.P.C. Layout, nd Vijayanagar 2 stage, Bangalore - 560 040 st Ph: 23404000, 23383142 Fax : 23202345 E-mail kspcblr@gmail.com Web : www.kspcdic.com :
Timings: 10.00 a.m. - 1.00 p.m.

INSTRUCTIONS TO OBTAIN REGISTERED PHARMACIST CERTIFICATE

1,050/The following documents have to be submitted along with a fee of Rs._______ in the form of K.S.P.C and 2,500/Rs._______ in favour of K.R.P.W.T.

1. D.Pharm / B.Pharm / M.Pharm / Certificate in original with A4 Size Xerox copy (each). 2. Marks Card of First and Final year D.Pharm / B.Pharm / M.Pharm in original with A4 Size xerox copy. 3. S.S.L.C. Marks Card / Transfer Certificate / Cumulative Record in original in support of Date of Birth with one A4 Size Xerox Copy) 4. Recent passport size colour photos (2 Nos.) with candidate signature on the back of the photos. Photographs to be identified by the Principal of your college or any Gazetted officer with seal and signature. 5. Blood Group report issued by a pathology laboratory / hospital. 6. Letter of PCI addressed to the principal regarding the approval stuatus of the college to conduct D.Pharm / B. Pharm / M. Pharm course for the admission year of the student.

Note: The Registrar reserves the right to call for any document/s to satisfy himself on the eligibility of the Applicant for registration.

Encl : 1. Form G - Scroll down 2. Declaration 3. Information Sheet

Karnataka State Pharmacy Council

Vijayanagar, Bangalore 560 040

FORM G
(See rule 48) APPLICATION FOR FRESH REGISTRATION OF PHARMACIST (Under the Pharmacy Act, 1948)

T o, The Registrar, Karnataka State Pharmacy Council No. 514/E, 1St Main, Vijayanagar Club Road, R.P.C. Layout, Vijayanagar 2nd Stage, Bangalore 560 040.

Sir,

Siganature

1. I request that my name may be registered as a Pharmacist and that I may be issued the Registration Certificate Under the Pharmacy Act, 1948 of Registration. 2. Particulars requested are given on the reverse of this application. 3. I enclose herewith for your perusal and return the Certificate in their Original and their copies for record in your office. 4. I hereby declare that I have read carefully and understood the instructions and particulars supplied to me and that all entries on the reverse of this application and the information sheet are true to the best of my knowledge and belief. 5. I agree that I will follow the rules of the Pharmacy Council which may be laid down for the guidance of the Registered Pharmacists from time to time. 6. I agree to produce the valid Identity Card on demand by the Inspector of Pharmacy Council / Drugs Inspector / any other officer authorized by the Government of Karnataka form time to time. 7. I agree to furnish any change in my address to the council. 8. I am enclosing a D.D.No. ........................Dated ........................ Of Rs................... In favour of The Registrar, Karnataka State Pharmacy Council, Bangalore.

Place :----------------------------Date :-------------------------------

Your faithfully,

Signature: ------------------------------------------------------------(Name in Capital Letters) Specimen Signature of the Applicant

1.

2.

3.

1. Applicant's Name in full (In Capital's Letters) 2. Father's Name (In Capital's Letters) Mothers Name (In Capital's Letters) Husbands Name (In Capital's Letters) 3. Place and Date of Birth (Proof of age to be attached)

Place :
Date Date of Birth: Month Year

4.

Nationality

5.

Current place of work with full address

6.

a. Current Residential Address in Karnataka State

......... ..............................................................................: ......... ..............................................................................: ......... ..............................................................................:

Ph :.................................................Mob: ............................................ E-mail :..............................................................................................:

......... ..............................................................................:
b. Permanent Address

......... ..............................................................................: ......... ..............................................................................:

Ph :.................................................Mob: ............................................ E-mail :..............................................................................................:

7. Year of Passing the Matriculation examination or an examination prescribed as being equivalent to Matriculation examination (kindly attach Original Certificate with A4 size Xerox Copy) 8. Qualification (Please attach Original Certificate with a A4 size Xerox copy) 9. Month and Year of Passing the qualifying Pharmacy Examination. 10. Name of the Examining Body / University 11. Name of the institution where training was undergone (750 hrs for D.Pharm, 500 hrs for B.Pharm) as Per education regulation in force. 12. Name and address of the Institution from where the Qualification was secured

Date :-----------------------

Signature of the Applicant

KARNATAKA STATE PHARMACY COUNCIL

(Constituted Under Pharmacy Act. 1948) No. 514/E, 1 Main, Vijayanagar Club Road, R.P.C. Layout, Vijayanagar 2 stage, Bangalore 560 040.

Information sheet to be submitted with Form G

I. NAME OF THE PHARMACIST ( Mr. / Mrs. / Ms). II. REGISTRATION NO. III. FATHER'S / HUSBAND'S NAME

IV. RESIDENTIAL ADDRESS

PIN CODE E-mail: V. DATE OF BIRTH DATE AGE MONTH YEAR YEARS SEX

Tel / Mob:

VI. BLOOD GROUP M F

VII. OFFICIAL ADDRESS (PRESENT WORKING ADDRESS)

PIN CODE E-mail: VIII. QUALIFICATION CODE 01. D.Pharm 04. Ph.D., CODE 03. M.Pharm 06. Other specilaity :--------URBAN CODE 01.Chemists & Druggists 02.Teaching 03. Administration 04. Hospital 05. Industry 06. None XII. OTHER DETAILS D. Pharm Certificate No. B. Pharm Certificate No. M. Pharm Certificate No. Ph.D Certificate No. Pharm.D Certificate No. Name of the University Name or the Institution & Address RURAL

Tel / Mob:

02. B.Pharm 05. Qualified Person

XI. PLACE OF PRACTICE

&
101. Private 102. State Govt. 103. Central Govt. 104. Public Sector 105. Industrial Estd., 106. Corporation 107. Zillapzrishat 108. Unemployed 109. Any other profession, Specify .........................................

Year of Passing Year of Passing Year of Passing Year of Passing Year of Passing

Note : USE CAPITAL LETTERS

USE

MARK WHEREVER REQUIRED

DECLARATION TO BE SUBMITTED ALONG WITH THE APPLICATION FOR REGISTRATION

I.

I ................................... hereby declare that I have not registered my name in any other State Pharmacy Council in India. This is my first application made with required enclosures for registration in this state after obtaining a Diploma / Degree in Pharmacy. I hereby declare that prior to this application, I had registered my name in State Pharmacy Councils detailed below.

II.

Registration Ist registration

Name of the Pharmacy Council

Registration No. And Date

Duration From To

Qualification

Ist Re- Registration

2 Re- Registration

nd

III.

I hereby declare that I desire to practice profession of pharmacy in the State of Karnataka by residing in this State . I hereby declare that the above information is true and correct to the best of my knowledge and belief.

IV.

V. I understand that my application is liable to be rejected summarily or the registration is liable to be cancelled forthwith, if the above information is proved to be false in any state before or after the issue of registration in addition to disciplinary proceedings and legal action.

Date : --------------------

Signature of the Applicant

KARNATAKA REGISTERED PHARMACISTS WELLFARE TRUST RULES AND CONDITIONS FOR ENROLLMENT IN THE TRUST 1. Candidate must be a Registered Pharmacists who has paid Life Team Registration in Karnataka state
Pharmacy Council. 2. Benefit under scheme will be given only if he is in the rolls of the Karnataka state Pharmacy Council at the time of the claim. 3. At the time of Enrollment the age should not exceed 60 years. 4. The quantum of amount to be given in case of death shall be a minimum amount of Rs.75,000/- which will be reviewed every year depending trust resources. 5. A partial disbursement up to 1/3 of the minimum amount for the medical treatment in case of serious illness such as cancer, cardiac surgery, kidney transplantation etc. to be decided by Trust Executive Committee on Merits. Such partial amounts paid will be deducted from final settlement to the nominee. RULES FOR CLAIMS : 1. In case of Death : Death Certificate issued by a competent authority in original shall be produced along with claim. 2. The claim shall be made in writing by the nominee whose is registered in the trust. 3. In case the Registered nominee is not alive at the time of claim, only the legal heir approved by the court of law Can make the claim producing the proof of their legal heir rights. The clam should be made with in 3 months (or 90 days) from the date of death. IN CASE OF MEDICAL CLAIM : A discharge certificate from the Hospital / Nursing Home indicate the brief report of illness and the treatment given should be produced in original or a certified copy.

KARNATAKA REGISTERED PHARMACISTS WELFARE TRUSTY (Reg.)

Vijayanagar, BANGALORE - 560 040)

APPLICATION FORM
(Fill in block letters only)

1. NAME OF THE APPLICANT (As appears in the registration certificate) 2. REGISTRATION NUMBER (copy of the certificate to be attached) 3. FATHERS / HUSBAND'S NAME 4. SEX

: : :

MALE

FEMALE

5. AGE / DATE OF BIRTH

: D D M M Y : Y Y Y

6. MARTIAL STATUS 8. ADDRESS (permanent)

: :

MARRIED / SINGLE

7. BLOOD GROUP

Preferred Mailing Address

9. NAME OF THE NOMINEE

(Recent passport size colour photos (2 Nos.))

: Specimen signature of the Nominee : 1.

Affix photo of the nominee

2.

3.

10. AGE & DATE OF BIRTH OF THE NOMINEE 11. RELATIONSHIP TO THE APPLICANT 12. IN CASE OF MINOR, PLEASE MENTION GUARDIANS NAME 13. ADDRESS OF THE NOMINEE

Yrs D D M M Y Y Y Y

: : :

13. MODE OF PAYMENT

: DD / PAY ORDER NO. ..................................................................................... BANK: . .................................................................. PLACE: .........................

Note : DD to be sent in favour of Karnataka Registered Pharmacist Welfare Trust, payable at Bangalore -----------------------------------------------------------------------------------------------------------------------------------------------------------I, the undersigned solemnly confirm that the above particulars are true to the best of my knowledge and belief. Further, I declare that I Shall abide by the rules and regulations laid by the Trust from time to time. DATE : Signature of Applicant

-----------.---------------------------------------------------------------------------------------------------------------------------------------For office use only Verification remark by office: Enrollment No. : MANAGING TRUSTEE