Inspection proforma for

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on non-judicial stamp paper)

I, Dr. ______________________ S/o, D/o, W/o ___________________ presently working full-time as _______________________ (mentioned designation) in ______________________ (name and address of the Dental College), solemnly affirm and declare that I am not working in any other institution in any capacity and not in full-time private practice.

I also solemnly affirm and declare as under :-

Date of Birth : __________________________



College of Study


Year & Month of Passing


Registration No. of UG & PG with date

Name of the State Dental Council



Any Other


Details of the previous appointments/teaching experience after MDS Qualification only if employed on full-time basis as teaching experience on part-time/visiting basis or on daily wages basis are not acceptable and will not be taken into consideration for determining length of teaching experience :


Name of Institution



Total Experience


Lecturer (Full-time)

Asstt. Professor /Reader (Full-time)

Associate Professor (Full-time)

Professor (Full-time)

Dean/Principal (Full- time)


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  1. Before joining present institution I was working at _________________________ as ______________________________ and relieved on ___________________ after resigning/retiring.

(a) Relieving Order No. & Date :

(Enclose copies of Relieving Order, Experience Certificates, T.D.S. Certificate)

(b) Appointment Order No. & Date

of the previous appointment :

(Copy attached)

A certified copy of – (a) Appointment letter of the previous institutions, (b) Resignation to the previous institutions or Relieving letter from the previous institutions are attached.

  1. I am not working in any other medical college/dental college in the State or outside the State in any capacity viz. full-time/part-time.

  2. TDS Deduction yearly for last three years :

S. No.

Financial Year

Total Tax Deducted Yearly




(A certified copy each of my Form 16 (TDS certificate) for financial years* ____________________________________ is attached)
* In the case of Professor last three financial years and in the case of Reader last one financial year.
For proof of the residential Address please attach any one of the following documents :- (a) Ration Card (b)Telephone Bill in the name of Deponent (c) Election Card (d) Water Bill in the name of Deponent (e) Proof of Children Education (f) Electricity Bill in the name of Deponent

Phone & Fax Number of Dental College :

Address of Office :

Phone No. :

Address of Residence :

Phone No. :

E-Mail address :

Date of Joining the present Institution :

PAN No. I.T. Circle :




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Full time/Part time


I have been appointed as full-time Professor/Reader/Lecturer at the said college.
Appointment Order No. & Date

of the present appointment :

(Copy attached)

Salary offered on the U.G.C. Pay-scales


I have been offered UGC Pay-Scales for the above-said post by the above college authority

Letter of Acceptance


I have accepted the above offer (a copy of the letter of acceptance is enclosed).

I also solemnly declare that the information furnished herein is true to the best of my knowledge and nothing has been concealed and no statement made therein is false.

[N.B. Please note that making false statement in the affidavit will attract the relevant provision of the Indian Penal Code etc.]

Date :
Counter Signature
This is to certify that the information given by the above deponent is correct and nothing has been concealed therefrom and deponent is working in the _______________ (department) as _______________ (designation) as a full-time teacher in our college and is not engaged in full-time private practice anywhere.
[N.B. Please note that making false statement in the affidavit will attract the relevant provision of the Indian Penal Code etc.]

Chairman of the Trust

Seal with Date

Principal of the College with seal

Attestation by Notary Public/Oath Commissioner


Dr. ……………………………………….

S/o, W/o, D/o ……………………………

Identified by Shri ……………………….

has solemnly affirmed before me at ____

on ……………….. at Sl. No. ……………

that the contents of the affidavit which

have been read and explained to him/her

are true and correct to his/her knowledge.

Signature Notary Public/Oath Commissioner

We have verified all the relevant documents and confirmed that information given are true to our knowledge and the above staff member was present during the inspection.

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