Form Of Application For Registration Of Pharmacy Page 2

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4.
Nationality
___________________________________________________________________
5.
Permanent Residential Address along with Phone No. and E-mail address
___________________________________________________________________
___________________________________________________________________
6.
Address of the Hospital/Dispensary or other place in which employed at present
___________________________________________________________________
7.
Years of passing Matriculation Examination or an Examination prescribed as
being equivalent to Matriculation Examination (Kindly attach original certificate
with a photocopy attested)
___________________________________________________________________
8.
Years of passing 10+2 Examination or an Examination prescribed as being
equivalent to 10+2 Examination. (Kindly attach original certificate with a
photocopy attested)
___________________________________________________________________
9.
Description of Qualification as Pharmacist (Kindly attach original certificate
with attested copies of each)
___________________________________________________________________
10. Name of the Examining body-Board/University
___________________________________________________________________
11. Name of the institution under which training undergone
___________________________________________________________________
12. Year of passing the Examination
___________________________________________________________________
13. Name of the institution/College from which Degree/Diploma has been obtained
___________________________________________________________________
Dated
Signature

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