Declaration Forms 22-23

Rajiv Gandhi University of Health Sciences, Karnataka
4th ‘T’ Block, Jayanagar, Bangalore – 560 041
Name of the College : _______________________________________________________
Date of Inspection : _________________________________
STAFF DECLARATION FORM – 2021 – 2022
1.(a) Dr./Mr./Mrs./ Name…………………………………………………………….
1.(b) Date of Birth & Age …………………………….………………………………..
1.(c) Recent Passport size photo of the Employee Photograph

Signed by Dean / Principal of the college.
1.(d) Submit Photo ID proof issued by Govt. Authorities :
Photo ID submitted: Aadhaar / Passport copy / Driving License / PAN Card / Voter ID
Number ……………………… Issued by …………………………… Photograph
Without Photo ID, Declaration form will be rejected and will not be considered as
teaching faculty.
1.(e) i. Present Designation:________________________________________________________
1.(e) ii. Department________________________________________________________________
1.(e) iii. College: ___________________________________________________________________
1.(e) iv. City: ______________________________________________________________________
1.(e) v. Nature of appointment: Permanent / Temporary / Adhoc / Honorary / Part-

time
1.(e) vi. Whether belongs to: SC / ST / OBC / Ex-service / Others.
1.(f ) Residential Address of employee :

______________________________________________________________
________________________________________________________________
_________________________________________________________________
1.(g ) Copy of Passport / Aadhaar / Voter Card / Ration Card / Electricity Bill /
Driving License Attached as a proof of residence.
1.(h ) Phone & Fax Number With Code: Office:

_________________________________
Residence: _________________________________
E-mail address: _________________________________
Mobile Number : _________________________________
1.(i ) Date of joining present institution : ________________________ as

______________________
2. Qualifications:
Qualification College & Year Registration No. Name of the State

Univ. of UG & PG Council
with date
Under
Graduate
Degree :
Post
Graduate
Degree :
Additional
Qualification:
Note: For PG-Post PG qualification additional Registration certificate particulars be

furnished and subject be furnished within brackets after scoring out whichever is not
applicable.
2.(a ) Copies of Degree certificates of UG and PG degree to be attached.

2.(b ) Copies of Registration of UG and PG degree to be attached.
3. Details of the previous appointments/teaching experience:
Position Name of From To Total

Institution DD/ DD/ Experience
MM/YY MM/YY in years &
months
Tutor/
Demonstrator
Registrar/
Sr.Resident
Assistant
Professor
Associate
Professor
Professor
4 .(a )Before joining present institution I was working at ________________________________

as
_____________________________________ and relieved on ______________________ after
resigning / retiring (Relieving order is enclosed from the previous institution).
4 .(b )I am not working in any other college in the State or outside the State in any capacity
full-time / part-time.
5 . Number of Research publications in Journals during the last 3 (Three) academic

years :
5 .(a ) International Journals: ___________________________
5 .(b ) National Journals: ___________________________
5 .(c ) State/Other Journals: ___________________________
6. Number of Research Projects on hand: ___________________________
7 .(a ) I am having PAN Card and my PAN is ____________________/ I am not having PAN
Card.
7 .(b ) I have drawn total emoluments from this college as under in the previous one year:-
Amount Received TDS

July,
August,
September,
October,
November,
December,
January,
February,
March,
April,
May,
June,
7 .(c ) (Copy of my PAN & Form 16 (TDS certificate) for financial year 2016-2017 are
attached)
Declaration
1. I have not worked at any other college/institution or presented myself at any

inspection from October 2019 onwards till date.
2. It is declared that each statement and/or contents of this declaration and /or
documents, certificates submitted along with the declaration form, by the
undersigned are absolutely true, correct and authentic. In the event of any
statement made in this declaration subsequently turning out to be incorrect or false
the undersigned has understood and accepted that such misdeclaration in respect to
any content of this declaration shall also be treated as a gross misconduct thereby
rendering the undersigned liable for necessary disciplinary action.
Date: Place: Signature of the Employee:
Endorsement
This endorsement is the certification that the undersigned has satisfied himself
/herself about the correctness and veracity of each content of this declaration and
endorses the abovementioned declaration as true and correct. I have verified the
certificates/ documents submitted by the candidate with the original
certificates/ documents as submitted by the teacher to the institute and with
the concerned institute and have found them to be correct and authentic.
In the event of this declaration turning out to be either incorrect or any part of
this declaration subsequently turning out to be incorrect or false it is understood and
accepted that the undersigned shall also be equally responsible besides the declarant
himself/herself for any such misdeclaration or misstatement.
Date: Place: Countersigned by the

Director/Dean/Principal
Sl.No Documents Submitted
1.(c) Recent Passport size photo of the Employee, Signed Yes No
by Dean / Principal of the college.
1.(d) Photo ID proof issued by Govt. Authorities : Yes No
Aadhaar / Passport / Driving License / PAN Card /
Voter ID
1.(g) Copy of Aadhaar / Passport /Voter Card / Ration Yes No
Card / Electricity Bill / Driving License Attached as
a proof of residence.
2.(a) Copies of Degree certificates of UG and PG degree. Yes No
2.(b) Copies of Registration of UG and PG degree. Yes No
3. Copy of experience certificate for all teaching Yes No
appointments held before joining present institute.
4.(a) Relieving order from the previous institution. Yes No
7.(a) PAN Card Yes No
7.(c) Form 16 (TDS certificate) for previous financial year Yes No
Signed by the Teacher : Countersigned by Dean Signed by the Inspector

/ Principal :
Date : Date : Date :
NOTE :
1. The Declaration Form will not be accepted and the person will not be counted
as teacher if any of the above documents are not enclosed / attached with the
Declaration Form.
2. The person will not be counted as a teacher if the original of Photo ID proof,
Registration Certificates / Degree certificates / PAN Card (if issued) are not
produced for verification at the time of inspection.
3. All the teachers must submit the revised declaration form in this format only.
(Any declaration form submitted in an old format will not be accepted and he
will not be counted as a teacher.)
(The Principal/Authorized Signatory has to put his/her signature along with official seal on all
the pages including Annexures and Supporting Documents)

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Rajiv Gandhi University of Health Sciences, Karnataka

4th ‘T’ Block, Jayanagar, Bangalore – 560 041

Name of the College : _______________________________________________________

Date of Inspection : _________________________________

STAFF DECLARATION FORM – 2021 – 2022

1.(a) Dr./Mr./Mrs./ Name…………………………………………………………….

1.(b) Date of Birth & Age …………………………….………………………………..

1.(c) Recent Passport size photo of the Employee Photograph

1.(d) Submit Photo ID proof issued by Govt. Authorities :

Number ……………………… Issued by …………………………… Photograph

1.(e) i. Present Designation:________________________________________________________

1.(e) ii. Department________________________________________________________________

1.(e) iii. College: ___________________________________________________________________

1.(e) iv. City: ______________________________________________________________________

1.(e) v. Nature of appointment: Permanent / Temporary / Adhoc / Honorary / Part-

1.(e) vi. Whether belongs to: SC / ST / OBC / Ex-service / Others.

1.(f ) Residential Address of employee :

1.(h ) Phone & Fax Number With Code: Office:

E-mail address: _________________________________

Mobile Number : _________________________________

1.(i ) Date of joining present institution : ________________________ as

Qualification College & Year Registration No. Name of the State

Note: For PG-Post PG qualification additional Registration certificate particulars be

2.(a ) Copies of Degree certificates of UG and PG degree to be attached.

Position Name of From To Total

4 .(a )Before joining present institution I was working at ________________________________

5 . Number of Research publications in Journals during the last 3 (Three) academic

5 .(a ) International Journals: ___________________________

5 .(b ) National Journals: ___________________________

5 .(c ) State/Other Journals: ___________________________

6. Number of Research Projects on hand: ___________________________

Amount Received TDS

1. I have not worked at any other college/institution or presented myself at any

Date: Place: Signature of the Employee:

Date: Place: Countersigned by the

Signed by the Teacher : Countersigned by Dean Signed by the Inspector

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