5/12/23, 9:52 AM Application Form

U.P. Pharmacy Council

Lekhraj Market-2, II floor, Indira Nagar, Lucknow
Application Form for Pharmacist's Registration

1) Application No. UPPCR0025762 2) Applicant Name Mr. Mohd Kaif

3) Gender Male 4) Date of Birth 08/06/1997

5) Place of Birth Andhipur 6) Father's Name Seraj Ahmad

7) Category Obc 8) Religion Islam

9) Mobile No. 8808570392 10) Aadhaar No. XXXXXXXX 5591

Permanent Address
11) House No. 194 12) Village/Locality Andhipur

13) PS (Police Station) Phoolpur 14) District Azamgarh

15) State Uttar Pradesh 16) Country India

17) PIN Code 223222 18) Nationality Indian

Correspondence Address
19) House No. 194 20) Village/Locality Andhipur

21) PS (Police Station) Phoolpur 22) District Azamgarh

23) State Uttar Pradesh 24) Country India

25) PIN Code 223222 26) Nationality Indian

Description of Education Qualification

Course Started in Course Ended in Maximum Obtained Secured

Qualification Examining Body Name Name of Institution CGPA
Year Year Marks Marks (%)

High School UP BOARD ASHRAFIA INTER COLLEGE MAHUL AZAMGARH 2014 2015 600 401 66.83 NA

Intermediate UP BOARD ASHRAFIA INTER COLLEGE MAHUL AZAMGARH 2016 2017 500 312 62.4 NA

BOARD OF TECHNICAL MATA DULARI DEVI PHARMACY COLLEGE

D. Pharma 2019 2021 2200 1818 82.64 NA
EDUCATION UP PHOOLPUR AZAMGARH

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5/12/23, 9:52 AM Application Form
Details of Last Degree Obtained
27) Roll No. 2044292141029 28) Degree Name D. Pharma

MATA DULARI DEVI PHARMACY

29) Address 30) District Azamgarh
COLLEGE PHOOLPUR AZAMGARH

31) State Uttar Pradesh 32) PIN Code 276304

Internship Details
33) Hospital / Organization Name C H C Khutahan Jaunpur

34) Address KHUTAHAN JAUNPUR 35) District Jaunpur

36) Internship Period (From) 30/09/2021 37) Internship Period (Till) 04/01/2022
Uploaded Documents

38) Photograph 39) Signature

40) High School Marksheet Uploaded

41) High School Certificate Uploaded

42) Intermediate Marksheet Uploaded

43) Intermediate Certificate Uploaded

44) D. Pharma Marksheet Uploaded

45) D. Pharma Certificate Uploaded

46) Internship Certificate Uploaded

47) Scanned copy of valid ID proof (Aadhaar Card/ Voter ID / Residence Certificate) Uploaded

48) Affidavit Uploaded

Declaration
I hereby declare that all the information submitted by me in this application form is correct, true and valid. If any ambiguity in the certificates produced by me is noticed, my registration will be
cancelled automatically with immediate effect and the council will be completely free to take action, for which I myself will be responsible.

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