Teaching Staff for Medical Course

(Use separate sheet for each specialty / Department and to be signed by the Principal / Dean)

Name of the College:

Name of the faculty Experience Phone No. E-mail ID

Principal

Medical
Superintendent

Specialty Name of the faculty Experience Phone No. E-mail ID Unit

Department of Anatomy

Professor

Associate Professor

Asst. Professor

Tutor / Demonstrators

Department of Physiology

Professor

Associate Professor

Asst. Professor

Tutor / Demonstrators

Department of Biochemistry

Professor

Associate Professor

Asst. Professor

Tutor / Demonstrators

Department of Pathology

Professor

Associate Professor
 Specialty Name of the faculty Experience Phone No. E-mail ID Unit

Asst. Professor

Tutor / Demonstrators

Department of Microbiology

Professor

Associate Professor

Asst. Professor

Tutor / Demonstrators

Department of Pharmacology

Professor

Associate Professor

Asst. Professor

Tutor / Demonstrators

Department of Forensic
Medicine

Professor

Associate Professor

Asst. Professor

Tutor / Demonstrators

Department of SPM

Professor

Associate Professor

Asst. Professor

Epidemiologist- Cum /Asst.

Professor

Statistician - Cum /Asst.

Professor

Tutor / Demonstrators
 Specialty Name of the faculty Experience Phone No. E-mail ID Unit

Medical Officer Health Cum

Lecture / Asst. Professor Rural
Training

Lady Medical Officer

Medical Officer Health Cum

Lecture / Asst. Professor Urban
Training

Lady Medical Officer

Department of General
Medicine

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident

Department of TB & RD

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident

Department of DVL

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident
 Specialty Name of the faculty Experience Phone No. E-mail ID Unit

Department of Psychiatry

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident

Department of Pediatrics

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident

Department of General Surgery

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident

Department of Orthopedics

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident
 Specialty Name of the faculty Experience Phone No. E-mail ID Unit

Department of ENT

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident

Department of Ophthalmology

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident

Department of OBG

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Jr. Resident

Antenata Medical Officer Cum –

Lecturer / Asso. Professor

Maternity & Child welfare

Officer Cum – Lecturer / Asso.
Professor

Department of Radio diagnosis

Professor

Associate Professor

Asst. Professor

Tutor / Registrars
 Specialty Name of the faculty Experience Phone No. E-mail ID Unit

Department of Radio therapy

(Optional)

Professor

Associate Professor

Asst. Professor

Tutor / Registrars

Department of Anesthesiology

Professor

Associate Professor

Asst. Professor

Tutor / Registrars / Sr. Resident

Department of Physical
Medicine & Rehabilitation
(Optional)

Professor

Associate Professor

Asst. Professor

Sr. Resident

House Surgeon / Jr. Resident

Department of Dentistry

Professor

Associate Professor

Asst. Professor

Tutor / Registrar

Signature of the Principal

 Teaching Staff for Dental Course

Name of the College:

Name of the faculty Experience Phone No. E-mail ID

Principal

Specialty Name of the faculty Experience Phone No. E-mail ID

Prosthodontics, Crown Bridge, Aesthetic Dentistry and Oral Implant logy

Professor

Associate Professor

Asst. Professor

Oral Pathology, Microbiology & Forensic Odontology

Professor

Associate Professor

Asst. Professor

Conservative, Endodontics & Aesthetic Dentistry

Professor

Associate Professor

Asst. Professor

Oral & Maxillofacial Surgery and Oral Implantology

Professor

Associate Professor

Asst. Professor

Periodontology & Oral Implantology

Professor

Associate Professor

Asst. Professor

Orthodontics & Dento-facial Orthopedics

Professor

Associate Professor

Asst. Professor
 Specialty Name of the faculty Experience Phone No. E-mail ID

Pedodontics & Preventive Dentistry

Professor

Associate Professor

Asst. Professor

Oral Medicine & Radiology

Professor

Associate Professor

Asst. Professor

Public Health Dentistry & Preventive Dentistry

Professor

Associate Professor

Asst. Professor

Dental Materials

Professor

Associate Professor

Asst. Professor

Dental Anatomy/Oral Biology

Professor

Associate Professor

Asst. Professor

Signature of the Principal

 MEDICAL TEACHING STAFF IN DENTAL COLLEGES

Specialty Name of the faculty Experience Phone No. E-mail ID

Anatomy

Professor

Associate Professor

Asst. Professor

Physiology

Professor

Associate Professor

Asst. Professor

Biochemistry

Professor

Associate Professor

Asst. Professor

Pharmacology

Professor

Associate Professor

Asst. Professor

General pathology

Professor

Associate Professor

Asst. Professor

Microbiology

Professor

Associate Professor

Asst. Professor

General Medicine

Professor

Associate Professor
 Specialty Name of the faculty Experience Phone No. E-mail ID

Asst. Professor

General Surgery

Professor

Associate Professor

Asst. Professor

Anesthesia

Professor

Associate Professor

Asst. Professor

Signature of the Principal

 FACULTY IDENTIFICATION FORM

1. Name of the faculty

2. Council Registration No.

(if applicable)
3. Designation

4. Department

5. College

6. City

7. Date of Birth

8. Residential Address

9. Telephone No. Residence:

With STD Code Office:

Mobile:

10. E-Mail address

11. Nature of appointment

Tick (√ ) appropriate [ Permanent/ Temporary/ Adhoc/ Honorary/ Part Time]

12. Date of joining

13. Aadhar Card No:

( Enclose copy)

14. In case of not having Aadhar Card

enclose any one photo ID Tick (√ ) [ Passport Copy/ Driving License/ Pan Card/ Voter ID]
appropriate ( Enclose copy)

15. Employee Photo Employee’s Thumbprint Employee Signature

Dean/ Principal’s Signature

15. Qualifications:

Registration No. of UG
College & Name of the
Qualification Year & PG with date (if
University Council
applicable)

DEGREE

POST
GRADUATION

HIGHER
SPECIALITY (if
any)

16. Details of Teaching Experience:

Name of the From To Total experience in

Designation Department
Institution DD/MM/YY DD/MM/YY Years & Months

Before joining present institution I was working at ____________________________ as

________________________________________ and relieved on ___________ after resigning/ retiring.

I am having PAN Card and my PAN is __________________________ / I am not having PAN Card.
 DECLARATION

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 miss
declaration 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 (including
making the individual ineligible for any University activity)

Faculty:

Signature: Date: Place:

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 endorse the above
mentioned 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.

Date: Place: Countersigned by the Director/ Dean/ Principal

Directives to fill this form:

1. All the teachers must submit the application in this format only.
2. Please attach photo ID/ PAN Card/ Pass Port Copy/ Electricity Bill/ Driving License/
Voters Card as proof of residence and ID Proof with the Form.
3. Please fill the form in block letters using black ink only.
4. Information must be in legible hand writing.
5. Only left thumb impression is to be marked with in the box provided.
6. Please affix Passport Photo Graph of the size as given in the Form.
7. Please sign only within the boxes provided.
8. Enclose copies of all the relevant Certificates/ Orders.