NAME OF THE COLLEGE : ____DIAMOND HARBOUR GOVT.

MEDICAL
COLLEGE

Date of
Remarks
Assessment
Accepted?
(YES/NO)
Name of the
Assessor
Signature of
Assessor

DECLARATION FORM : 2019-20 - FACULTY

(Note : It is responsibility of Dean, HOD & faculty to submit only the
declaration form of faculty who has not appeared for assessment in any
other college during the academic year and working as full time)
1.(a) Name: Pabitra Kr. Goswami RECENT
PHOTOGRAPH TO
1.(b) Date of Birth & Age 28.05.1967 51yrs 8months BE
COUTERSIGNED
1.(c) Submit Photo ID proof issued by Govt. Authorities : BY THE
Photo ID submitted : PAN Card DEAN/PRINCIPAL

Number AFFPG0300R Issued by IT Dept. Govt. of India

Note: 1) Without Photo ID, Declaration form will be rejected and will not be
considered as teaching faculty. 2) Original Certificates are mandatory for
verification. All Certificates/Documents/Certified Translations, must be in
English

1.(d) i. Present Designation: Associate Professor

1.(d)(i)a Certified copies of present appointment order at present institute

attached.

1.(d)ii. Department: General Surgery

1.(d) iii. College: Diamond Harbour Govt. Medical College

1.(d)iv. City: Diamond Harbour, 24PGS , North, WB

1.(d) v. Nature of appointment: (a) Regular / Contractual /Adhoc Regular
(b) Full time /Part time /Honorary Full time
(c) With Private Practic

1.(d)vi. Date of appearance in Last MCI – UG/PG/Any Other Assessment 21.02.17

In which college: Malda Medical College
1.(d)vii Whether appeared and accepted in Last MCI – UG/PG Assessment in the
same Institute – No
1.(d)viii Whether appeared and accepted in Last MCI – UG/PG Assessment on same
Designation – Yes
1.(d)ix Whether you have retired from Government medical college – No

Signature of Faculty Signature of Dean with stamp

1.(e ) (a) Present Residential Address of employee: 8T, Beerpara Lane, Kolkata -
700030

1.(e) (b) Permanent Residential Address of Employee : As above

1.(f) Have you undergone Training in ”Basic Course Workshop” at MCI

Regional Centre in MET or in your college under Regional Centre
observership?
NO
If yes, give details.

Name of MCI Regional Centre where Date and place of training

Training was done/If training was
done in college, give the details
of the observer from RC

1. (g) Copy of Passport /Voter Card / Electricity Bill /Landline Telephone Bill /
Aadhar Card / attached as a proof of residence. Yes

1. (h) Contact Particulars: Tel (Office) : 03174-255-442 (with STD code)

Tel (Residence): 9433013116 (with STD code)

E-mail address: goswamipabitra74@gmail.com

Mobile Number: as above

1. (I) Date of joining present institution: 05.03.2019 as Associate Professor

1. (j) Joining report at the present institute attached – Yes

2. Qualifications:

Registrati Name of the

Qualificatio
College University Year on No. State Medical
n
with date Council
R G Kar MCH CU 1991 50852, WBMC
08.12.1993
MBBS

MD/MS/DNB/ UCM CU 1998 As above WBMC

PhD

Subject :
_____
DM/M.Ch.

Subject :
_____

2
Note: For PG-Post PG qualification additional Registration certificate particulars
be furnished and subject be after scoring out whichever is not applicable.

2. (a ) Copy of Degree certificates of MBBS and PG degree attached – Yes

2. (b ) Copy of Registration of MBBS and PG degree attached – Yes
3 (a). Details of the teaching experience till date.
Designation Departme Name of From To Total
nt Institution DD/MM/ DD/MM/YY Experien
YY ce in
years &
months
Junior Resident

Senior
Resident

Tutor Surgery R G Kar MCH 25.05.2000 25.11.2003

Assistant
Surgery R G Kar MCH 25.11.2003 17.09.09
Professor

R G K MCH 17.09.09 17.02.12

Associate
Surgery Malda MCH 22.02.12 27.02.19
Professor
DHG MCH 05.03.19 Till date

Professor - - - -

3(b). To be filled in by Ex Army Personnel only:

S.N Period
Designation Institution
o. From To

Graded
1.
Specialist

Classified
2.
Specialist

3. Advisor

Note: Have you been considered in any UG/PG inspection at any other
institution/medical college during last 3 years. If yes, please give details.
I have been considered as Associate Professor in Malda MCH MCI inspection held on
21.02.17 19.07.16 & 04.0516

3
4. Before joining present institution I was working at Malda MCH as Asso. Professor (
Surgery) and relieved on 27.02.2019 after Transferring (Relieving order is
enclosed from the previous institution).

5. Number of Research publications in Index Journals:

5. (a ) International Journals: Libyan Journal of Surgery & others

5. (b ) National Journals: Indian Journal of Surgery
5. (c ) State/Institutional Journals: X

6. (a) My PAN Card No. is AFFPGO300R

6. (b) My Aadhar card No. is 3809 3691 3073

6. (c) I have drawn total emoluments from this college in the current financial year as
under:-

Month Amount Received TDS

April 2018
May 2018
June 2018
July 2018
August 2018
September 2018
October 2018
November 2018
December 2018
January 2019
February 2019
March 2019

6. (c ) (Copy of my PAN & Form 16 (TDS certificate) for financial year 2017-18 are
attached)

DECLARATION

1. I, Dr. Pabitra Kumar Goswami am working as Associate Professor in the

Department of General surgery at Diamond Harbour Govt. Medical College and
do hereby give an undertaking that I am a full time teacher in diamond Harbour
Govt MCH working from 9 A.M. to 4 P.M. daily at this Institute.
2. I have not presented myself to any other Medical College / Institution as a faculty
/ Resident in the current academic year for the purpose of MCI assessment.

4
3. I am practicing at various Nursing Homes in the city of Kolkata and my hours of
practice is yet to be fixed after latest transfer .Further I state that I am not doing
any Private Practice or not working in any other hospital during college hours.
4. Complete details with regard to work experience has been provided & nothing has
been concealed by me.
5. I am not working in any other medical college/dental college in the State or
outside the State in any capacity: Regular / Contractual / Adhoc --– Full time /
Part time / Honorary.
6. 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 misdeclaration 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 removal of his name from Indian Medical Register).

SIGNATURE OF THE EMPLOYEE

Date:
Place: Diamond Harbour

ENDORSEMENT
1. This endorsement is the certification that the undersigned has satisfied himself
/herself about the correctness and veracity of each content of this declaration
and endorses 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.
2. I also confirm that Dr. Pabitra Kr. Goswami is not practicing or carrying out any
other activity during college working hours i.e. from 9am to 4pm, since he/she
has joined the Institute.
3. In the event of this declaration turning out to be either incorrect or any part of
this declaration subsequently turning out to be incorrect or false it is understood
and accepted that the undersigned shall also be equally responsible besides the
declarant himself/herself for any such misdeclaration or misstatement.

Date: Signed by the HOD Countersigned with stamp

by the
Place: Director/Dean/Principal

5
REMARKS

S.No Documents Submitted

1. Recent Passport size photo of the Employee, Signed by Yes / No
Dean / Principal of the college.
2. Photo ID proof issued by Govt. Authorities : Passport / PAN Yes / No
Card / Voter ID / Aadhar Card
3. Certified copies of present appointment order at present Yes / No
Institute.
4. Copy of Passport /Voter Card / Electricity Bill / Telephone Yes / No
Bill / Aadhar Card / Dean’s allotment letter attached as a
proof of present residence.
4.(a) Copy of Passport /Voter Card / Electricity Bill / Telephone Yes / No
Bill / Aadhar Card attached as a proof of permanent
residence.
5. Joining report at the present institute. Yes / No
6. Copies of Degree certificates of MBBS and PG degree. Yes / No
7. Copies of Registration of MBBS and PG degree. Yes / No
8. Copy of experience certificate for all teaching appointments Yes / No
held before joining present institute.
9. Relieving order from the previous institution. Yes / No
10. PAN Card Yes / No
11. Form 16 (TDS certificate) for the last financial year. Yes / No
12. Letter head (in case of teachers who are practicing) Yes / No
13. Copy of U.G. recognized teacher letter from affiliated Yes / No
University.
14 Copy of P.G. recognized teacher letter from affiliated Yes / No
University.(for P.G. Assessment)
15 Copy of Aadhar Card Yes / No

Signed by the Teacher: Signed by the HOD:

Date : Date :

Countersigned with stamp by Dean / Principal:

Date :

Signed & Verified by the Assessor :

Date :

NOTE :

1. The Declaration Form will not be accepted and the person will not be
counted as teacher if any of the above documents are not enclosed /
attached with the Declaration Form.
2. The person will not be counted as a teacher if the original of Photo ID
proof, Registration Certificates / Degree certificates / PAN Card / State
6
 Medical Council ID (if issued) are not produced for verification at the time
of assessment.
3. All the teachers must submit the revised declaration form in this format
only. (Any declaration form submitted in an old format will not be accepted
and he will not be counted as a teacher.)

NAME OF THE COLLEGE :

_____________________________________________________

Date of
Remarks
Assessment
Accepted?
(YES/NO)
Name of the
Assessor
Signature of
Assessor

DECLARATION FORM : 2019-20 – RESIDENT (SR/JR)

(Note : It is responsibility of Dean, HOD & resident to submit only the
declaration form of resident, who has not appeared for assessment in any
RECENT
other college during academic year and working as full time) PHOTOGRAPH TO
BE RECENT
1.(a) Name…..…………………………………………………………………….. COUTERSIGNED PHOTOGRAPH TO
1.(b) Date of Birth & Age ……………………………………………………….. BY THEBE
1.(c) Submit Photo ID proof issued by Govt. Authorities : DEAN/PRINCIPAL
COUTERSIGNED
Photo ID submitted : BY THE DEAN/P
Passport copy / PAN Card / Voter ID/Aadhar Card.
Number ……………………….……………… Issued by ..………………………………..
………
Note: 1) Without Photo ID, Declaration form will be rejected and will not be
considered as teaching faculty. 2) Original Certificates are mandatory for
verification. All Certificates/Documents/Certified Translations, must be in
English
1.(d) i. Present
Designation:_________________________________________________________

1.(d)ii. Department:
_______________________________________________________________
1.(d) iii. College:
___________________________________________________________________
1.(d)iv.
City:_____________________________________________________________________
1.(d)v. Date of appearance in Last MCI – UG/PG/Any Other Assessment ______ in
which college____________________________
1.(d)vi Whether appeared and accepted in Last MCI – UG/PG Assessment in the
same Institute – Yes/No
1.(d)vii Whether appeared and accepted in Last MCI – UG/PG Assessment on same
Designation – Yes/No
1.(e)i. Campus / Present address of Resident :
___________________________________________________________________________

___________________________________________________________________________

Signature of Resident Signature with stamp of Dean

7
1.(e)ii. Permanent Address of Resident:
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

1.(f) Copy of Room Allotment Letter and permanent residential address proof
attached. Yes / No.
1.(g) Contact Particulars: Tel (Office):____________________________________(with STD
code)
Tel (Residence): ________________________________ (with STD
code)
E-mail address:
_______________________________________________
Mobile Number:
______________________________________________
1.(h) Date of joining present institution : _______________________ as ________________
1.(i) Joining report at the present institute attached - Yes/No
2. Qualifications :

Registrati Name of the

Qualificatio
College University Year on No State Medical
n
with date Council

MBBS

MD/MS/DNB

Subject :____
_

DM/M.Ch.

Subject :
_____

Note: For PG-Post PG qualification additional Registration certificate particulars

be furnished and subject be furnished within brackets after scoring out
whichever is not applicable.
2.(a ) Copies of Degree certificates of MBBS and PG degree attached –
Yes/No
2.(b ) Copies of Registration of MBBS and PG degree attached Yes/No

8
3. Details of the teaching experience till date.
Designation Departme Name of From To Total
nt Institution DD/MM/ DD/MM/YY Experien
YY ce in
years &
months
Junior Resident
1
Junior Resident
2
Junior Resident
3
Senior
Resident

4 .(a ) Before joining present institution I was working at

________________________________ as ____________________________________ and
relieved on _________________________ after resigning /Transferring /(Relieving
order is enclosed from the previous institution).
5. I have drawn total stipend from this college in the current financial year as under.
Month Amount Received
April 2018
May 2018
June 2018
July 2018
August 2018
September 2018
October 2018
November 2018
December 2018
January 2019
February 2019
March 2019

DECLARATION

1. I, Dr. _________________________________ am working as ________________________ in

the Department of _________________________ at _____________________________
Medical College and do hereby give an undertaking that I am a Full time Regular
Resident in _______________________________________, and am staying in Room No.
________ in the Residents’ Hostel in the college premises.
2. Further, I state that I am not doing any Private practice or not working in any
other hospital also at any time.
3. I have not worked at any other medical college/institution or presented myself at
any Assessment in the current academic year.

9
4. 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 misdeclaration 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 removal of his name from Indian Medical Register).

SIGNATURE OF THE RESIDENT

Date:
Place:
ENDORSEMENT

1. This endorsement is the certification that the undersigned has satisfied himself
/herself about the correctness and veracity of each content of this declaration
and endorses the abovementioned declaration as true and correct. I have
verified the certificates/ documents submitted by the candidate with
the original certificates/ documents as submitted by the Resident to the
institute and with the concerned institute and have found them to be
correct and authentic.

2. I also confirm that Dr. _______________________________ is working as full time

Regular Resident (i.e. for 24 hours) and is not practicing or carrying out any other
activity and is staying in Room No. _________ of the Residents’ Hostel in college
premises, since he/she has joined the Institute.

3. In the event of this declaration turning out to be either incorrect or any part of
this declaration subsequently turning out to be incorrect or false it is understood
and accepted that the undersigned shall also be equally responsible besides the
declarant himself/herself for any such misdeclaration or misstatement.

Date:
Place: Signed by the HOD Countersigned with stamp
by the
Director/Dean/Principal

10
 REMARKS

S.No Documents Submitted

1. Recent Passport size photo of the Employee, Signed by Dean / Yes / No
Principal of the college.
2. Photo ID proof issued by Govt. Authorities : Passport Copy / PAN Yes / No
Card / Voter ID / Aadhar Card
3. Certified copies of present appointment order at present institute. Yes / No
4. Copy of Allotment Letter by Dean as proof of present residence Yes / No
address.
4.(a) Copy of Passport /Voter Card / Electricity Bill / Telephone Bill / Yes / No
Aadhar Card attached as a proof of permanent residence
address.
5. Joining report at the present institute. Yes / No
6. Copies of Degree certificates of MBBS and PG degree. Yes / No
7. Copies of Registration of MBBS and PG degree. Yes / No
8. Copy of experience certificate for all appointments held before Yes / No
joining present institute.
9. Relieving order from the previous institution. Yes / No
10 Copy of Aadhar Card Yes / No

Signed by the Resident: Signed by the HOD:

Date: Date :

Countersigned with stamp by Dean / Principal.

Date :

Signed & Verified by the Assessor :

Date :

NOTE :

1. The Declaration Form will not be accepted and the person will not be
counted as Resident if any of the above documents are not enclosed /
attached with the Declaration Form.

2. The person will not be counted as a Resident if the original of Photo ID

proof, Registration Certificates / Degree certificates / PAN Card / MCI
Smart ID Card /State Medical Council ID ( if issued ) are not produced for
verification at the time of assessment.

3. All the Resident must submit the revised declaration form in this format
only. (Any declaration form submitted in an old format will not be
accepted and he will not be counted as a Resident)

11