Sr. No.
01
+(Affidavit/Self Declaration)
SPECIMEN OF SELF DECLARATION FOR FIRST REGISTRATION
To be submitted before the Registration Punjab Pharmacy Council
I____________________________S/o, D/o Father Sh.__________________________Mother Smt.
______________________________ R/o________________________________________________
______________________________________________do here by solemnly declare as under: -
1. That I have passed Matriculation Examination from (School, Place & Board Name) ___________
_______________________________________Tehsil___________Distt._____________in
theYear/Session__________________ and my date birth
is_________________________________________
2. That I have passed 10+2 Examination from (School, Place & Board Name) __________________
______________________________________ Tehsil___________ Distt._____________ in
theYear/Session___________ and I have already completed 18 year of age.
3. That I have passed my Diploma/Degree in pharmacy from________________________________
__________________________________________________________________________________
Distt._______________ State_____________ in year/session________________________________
4. I have undergone practical training/ Industrial Training (Please tick) in (Name of
Hospital/
Dispensary, Place) _____________________________________________ in Tehsil____________ of
Distt.______________________State____________________for____________________hoursfrom
____________ to__________ spread over a period of three months/ one month (Please tick)
5. That I declare under oath that I have genuinely obtained all my qualification & all Certificate of
Matrix, 10+2 & Diploma/Degree attached herewith are approved from the concerned
Board/University and PCI, New Delhi & are completely genuine & true. If found otherwise, I'll not
claim for Registration as Pharmacist. Furthermore, I shall alone be responsible for producing fake or
false certificates before the Registrar & Staff, PSPC and I may be held guilty & punished for this
offence not the Registrar orStaff, PSPC.
[Link] I am a domicile of Punjab being permanent resident of Vill.
__________________________________________________________________________________
Tehsil_______________ Distt._________________ in Punjab State. (Adhaar Card enclosed).
7. That I am not registered as a pharmacist anywhere in India with any other Pharmacy Council. I
have applied for the Registration with Punjab Pharmacy Council for the first time.
8. I undertake that my registration as Pharmacist may be cancelled if I found guilty of any offence
according to the Pharmacy Act, 1948 as amended and State Pharmacy Council Rules, 1951. I agree
that I will follow the Rules of Punjab Pharmacy Council which may be laid down for the guidance of
registered pharmacists from time to time.
VERIFICATION DEPONENT
I the above said deponent further declare that the above given statement is true to the
best of my knowledge and belief.
Dated:________________ DEPONENT
SPECIMEN OF SELF DECLARATION FOR FRESH REGISTRATION OF
PHARMACIST FROM ABROAD
To be submitted before the Registrar Punjab State Pharmacy Council
I_________________________S/o,D/o Father Sh.___________________________ Mother Smt.
__________________________ R/o__________________________________________
______________________________________________ do here by solemnly declare as under:-
1. That I have passed Matriculation Examination from (School, Place & Board Name)___________
____________________________________________________________Tehsil____________
Distt.___________ in the Year/ Session____________.
[Link] I have passed 10+2 Examination from (School, Place & Board Name)____________________
__________________________________________________________Tehsil____________
Distt.____________ in the Year/Session ________ and I have already completed 18 year of age.
[Link] I have passed my Diploma/Degree in Pharmacy from_____________________________
_____________________________________________Distt. _________________ State
________________ in year/session ______________.
4.I have undergone practical training (Industrial) in (Name of Hospital/Dispensary,Place)
________________________________________________________________________in
Tehsil ____________ of Distt. __________ State __________ for ______ hours from
_________to _______spread over a period of three months.
[Link] I declare under oath that I have genuinely obtained all my qualifications & all my
Certificates of Matric, 10+2 & Diploma/Degree attached herewith are approved from the
concerned Board/University and PCI, New Delhi & are completely genuine & true . If found
otherwise, I’ll not claim for Registration as Pharmacist. Furthermore I shall alone be responsible
for producing fake or false certificates before the Registrar & Staff, PSPC and I may be held guilty
& punished for this offence not the Registrar or Staff, PSPC.
[Link] I am a domicile of Punjab being permanent resident of Vill. ______________
_______________________________________________________________________Tehsil
_________________Distt. _______________in Punjab State. (Adhaar Card enclosed)
7. That I am not registered as a pharmacist anywhere in India with any other Pharmacy Council.
I have applied for the Registration with Punjab Pharmacy Council for the first time.
8.I undertake that my registration as Pharmacist may be cancelled if I found guilty of any offence
according to the Pharmacy Act,1948 as amended and State Pharmacy Council Rules,1951. I agree
that I will follow the Rules of Punjab Pharmacy Council which may be laid down for the guidance
of registered pharmacists from time to time.
VERIFICATION DEPONENT
I the above said deponent further declare that the above given statement is true to
the best of my knowledge and belief.
Dated: - _________________ DEPONENT