Faculty/ SR/ Tutor/ Demonstrator Declaration Form

Name of the College: Shri M.P Shah Government Medical College Jamnagar

Submission date _ _ /_ _ /_ _ _ _
Note: It is the responsibility of the Dean to ensure that the submitted Declaration form is ONLY of a Faculty member who is working as a full-
time employee of the college
Attach a recent
1. Name of Faculty: (Last name) (First name) (Middle name) passport size color
photograph with
2. Age & Date of birth: 52 (Years), 20 / 06 _ / 1972 signature and seal
of the Principal /
Dean across it
3. Present Designation: ______________________________________
Professor
a. Appointment order: Certified copy of order at this institute attached: Yes / No
b. Department: Department of Obstetrics & Gynecology
c. College/Institute: Shri M.P Shah Government Medical College Jamnagar

d. City / District: Jamnagar

e. Appointment: (i) Regular / Contractual /Ad-hoc basis

(ii) Full time / Part time
(iii) With Private practice / Without Private practice
f. Date of appearance in last MCI/NMC assessment:
i. UG / PG / Any other: UG
ii. Name of College: Shri M.P Shah Government Medical College, Jamnagar
iii. Whether appeared and accepted at the same College: Yes / No
iv. Whether appeared and accepted for the same designation: Yes / No
v. Whether retired from Government Medical College: Yes /No
vi. If yes, designation at the time of retirement:

Signature of the Faculty Signature & Seal of Dean

4. Complete Residential Address of the employee:
a. Present: 301 Shagun-3 Apartment, Behind Sunshine school
Valkeshwari Plot, Jamnagar, 361008

b. Permanent: Same as Present Address

5. Copy of Proof of Residence submitted and original verified: Yes / No

(Only copies of Passport/Aadhar card/Voter ID/Passport/Electricity bill/Landline Phone bill will be considered)
6. Contact details:
a. Office telephone with STD code: 0288-2553515

b. Residence telephone with STD code: 0288-2540100

c. Mobile Phone Number: 9662950807

d. Email address: drnitafin@gmail.com

7. Date of joining the present institution: 16 / 10 / 2024

8. Joining report verified / attached Yes / No

9. Have you attended the Basic Course Workshop (BCME), Curriculum Implementation Support
Programme (CISP-i/ii/iii), Advanced Course in Medical Education (ACME) for training in MET:
Yes / No.
(If Yes, provide certificate/s )
a. at MCI/NMC Regional MET Centre: Yes /No.
b. at your college under Regional / Nodal Centre observership: Yes / No
c. Any other MET certificates may be attached
10. Educational Qualifications:

Name of College & Registration number Name of State

Degree Year
University with date of registration Medical council
MBBS Shri M.P. Shah Govt Medical College Gujarat State Medical
Saurashtra University Council

MD/MS Shri M.P. Shah Govt Medical College Gujarat State Medical
Saurashtra University Council

DM/MCh

PhD

a. MD/MS subject: Obstetrics & Gynecology

b. DM/MCh subject:
c. PhD subject:

Note: For PG & Post PG qualifications, particulars of Registration of Additional Qualification certificates
are to be furnished for them to be accepted. Strike out whichever section is not applicable.

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 11. Copies of educational qualifications:
a. Copies of MBBS & PG Degree certificates verified and attached: Yes / No
b. Copies of MBBS & PG Degree Registration verified and attached: Yes / No

12. Details of Teaching experience till date:

Designation* Department Institution From To Total
Junior Resident OB&GY G.G Hospital _02
_/_
02_/_95_ _30
_/_12_/_97_ 2 (y) 11 (m)
Senior Resident OB&GY G.G Hospital _31
_/_
12_/_97_ _07
_/_08_/_98_ 0 (y) 8 (m)
NA I
Demonstrator NA _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)

Tutor NA NA _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)

Asst. Professor OB&GY G.G Hospital _08

_/_08_/_98_ _ _/_ _/_ _ (y) (m)

Assoc. Professor OB&GY G.G Hospital _ _/_ _/_ _ _ _/_ _/_ _ (y) (m)

Professor OB&GY G.G Hospital _16

_/_
10_/_24_ _Till
_/_Date
_/_ _ (y) (m)
* Write NA (Not Applicable) for the designations not held

To be filled in by personnel from Indian Defense Services ONLY:

Designation Institution* From To Total

_ _/_ _/_ _ _/_ _/_
Graded Specialist _ _
(y) (m)

_ _/_ _/_ _ _/_ _/_

Classified Specialist _ _
(y) (m)

_ _/_ _/_ _ _/_ _/_

Advisor _ _
(y) (m)

* Note: Documents in support of each posting to be furnished for verification

13. Have you been considered in UG/PG, MCI/NMC inspection at any other medical
college ina teaching or administrative capacity during last 3 years. If yes, please give
details:

Designation Subject College Dates

14. Number of lectures / small group teachings/ self-directed learning sessions/ clinics/ etc
taken and topics covered in last academic year (attach additional sheet, if required)

S.No. Date Lecture/ SGT/SDL/ Clinic/ others Topic

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15. Details of employment before joining the present institution:
a. Name of College/Institution: Shri M.P Shah Govt Medical College Jamnagar
b. Designation: Associate Professor Date on which relieved: _ _ / _06
_ / _2 _0 _0 8_
c. Reason for being relieved: Tendered resignation / Retired / Transferred / Terminated
d. Relieving order issued by previous institution verified and attached: Yes / No

16. PAN Card Number: ALHPS 8897F

17. Aadhar card Number: 7695 0638 8502
18. I have drawn total emoluments from this college in the current financial year as under:

Month Amount Received TDS

/ Year
NA
Jan/
NA
Feb/

March/ NA

April/ NA

May/ NA

June/ NA

July / NA

August/ NA

September/ NA
October/
NA
November/
NA
December/
NA

19. Number of Research articles in Indexed Journals:

a. International Journals: ____
b. National Journals: ____
c. State / Institutional Journals: _ _ _ _
20. Details of other publications:
a. Number of Books published: 01
b. Number of Chapters in books:

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21. Any other information/ achievements/ patents:
-Best InnovaIve Technique Award- IAGE 2008 on Technique for ConservaIve Laparoscopic
Surgery for prolapse
-Organising Secretary State conference Ob&Gy 2018
-President Jamnagar Ob&Gy Society 2021-23
-ExecuIve CommiVee Member ISAR Gujarat 2024-25
22. Oral presentations: in zonal conference:
State conference: Guest Speaker SOGOG 2015, 17, 18, 22
National conference: Guest Speaker ICOG-FOGSI 2024
International conference: NA
23. Poster presentations: in zonal/ State/ National/ International Conference.

NA

24. Awards/ prizes:

• Best InnovaIve Technique Award- IAGE 2008 on Technique for ConservaIve Laparoscopic Surgery for
prolapse
• YUVA FOGSI -2020 Award

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 DECLARATION
1. I, Dr. Nita Mandhai am working in the capacity of Professor

in the Department of Obstetrics & Gyanecology at

Shri M.P. Shah Govt Medical College and do hereby give an undertaking
that I am employed as a full time teaching faculty, working from _09_:_00_ A.M. to _05_:_00
_
P.M. daily at this Institute. If required I attend emergency duties.
2. I have not made myself available to any other Medical College/Institution in any discipline,
in the capacity of a teaching faculty, administrator or advisor in the current academic year
for the purpose of NMC/MCI assessments.
3. I do hereby solemnly declare that (tick the applicable clause):
a. I state that I am not doing any Private Practice or working in any other hospital
during college hours.
b. I practice at Shree Dwarkadhish Nursing Home / Clinic / Hospital
in the city of Jamnagar in Gujarat State and my hours of private
09:00
practice are from _08_:_00_ AM/PM to AM/PM. & Emergencies
05:00 PM 08:00 PM
4. I am not working in any other medical/dental college in or outside the State in any capacity:
Regular/Contractual/Ad-hoc or Full time/Part time/Honorary.
5. I declare that I have provided all details with regard to my work and teaching experience and
no information has been concealed by me.
6. I do solemnly declare that all the details/information furnished by me in this declaration form
is absolutely true and correct, and all the documents/certificates that were made available by
me for verification or have been submitted by me along with this declaration form are
authentic. In the event of any information furnished or statement made in this declaration
subsequently turning out to be false/incorrect or any document/s or certificate/s is/are found
to be out of order, or it comes to light that there has been suppression of any material
information, I understand and accept that it shall be considered as gross misconduct thereby
rendering me liable to disciplinary and/or legal proceedings. It might also lead to
suspension/cancellation of my Registration with the State Medical Council and/or removal
of my name from the Indian Medical Register.

Date: 08/11/24
Place: Jamnagar
(Signature of the Faculty)

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 ENDORSEMENT

1. This endorsement is the certification that the undersigned has satisfied herself/himself about
the correctness, authenticity and veracity of the content of this declaration form in its entirety
and endorsed the above declaration as true and correct. I have personally verified all the
certificates/documents submitted by the teaching faculty with the original certificates
and documents that were submitted by her/him to the Institute and confirmed the same
with the concerned Institute and have found them to be correct and authentic.

2. I also confirm that Dr. _ is not indulging in private practice

of any kind or carrying out any other professional or other commercial activity during college
working hours, from _ _:_ _ AM to _ _:_ _ PM, since she/he has joined the Institute.

3. In the event of this declaration turning out to be false or incorrect or any part of this
declaration subsequently turning out to be false or incorrect or it comes to light that there
has been suppression of any material information, it is understood and accepted that the
undersigned shall also be equally responsible besides the declarant herself/himself, for the
mis-declaration or mis-statement.

Date:
Place:

Signature (Head of Dept.) Signature (Head of Institute)

with official seal with official seal

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 CHECKLIST

Sl Documents Submitted
1. Recent Passport size photo of Employee, Signed by Dean/Principal of college Yes / No
2. Photo ID proof (Govt. Authority issued): Passport/PAN Card/Voter ID/Aadhar Card Yes / No
3. Certified copy of Appointment order of the present Institute. Yes / No
4. Proof of Residence: Passport/Voter Card/Electricity/Landline phone bill/ Aadhar Card Yes / No
5. Joining report at the present institute. Yes / No
6. Copies of MBBS, PG, PhD degrees (as applicable). Yes / No
7. Copies of MBBS, PG, PhD degree Registration Certificates (as applicable). Yes / No
8. Copy of experience certificates of all teaching appointments before joining present post. Yes / No
9. Relieving order from the previous institution/posting. Yes / No
10. Copy of PAN Card, AADHAR card Yes / No
11. Letter head (in case of teachers who are practicing) Yes / No
12. Copy of letter from affiliating University recognizing as UG teacher Yes / No
13 Copy of letter from affiliating University recognizing as PG teacher (for PG assessment) Yes / No
14 Copy of MET certificates: rBCW/ BCME/ CISP/ ACME/ Others Yes / No

Signature of Faculty Signature of the HoD.

Date: Date:

____________________________
Signature of Head of Institute
Date:

NOTE
I) This Declaration Form will not be accepted and the Faculty member will not be considered as a
Teaching Faculty in case any of the documents listed above are not enclosed/attached with the
Declaration Form.

II) The Faculty member will not be considered as a Teaching Faculty if the original Appointment letter,
Relieving order, Experience certificates, Government Photo ID, Degrees, Registration Certificates,
PAN Card, Aadhar Card, State Medical Council ID (if issued) are not produced for verification at the
time of assessment.

III) Faculty members must submit the revised Declaration form in this format only, Submissions in the old
format will be rejected and Faculty members will not be considered as Teaching Faculty.

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