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Registration

Basic Information

Fields marked with * are compulsory

NOTE :- BEFORE START FILLING ONLINE REGISTRATION FORM, GET SCANNED COPY OF ALL RELEVANT DOCUMENTS ON SYSTEM.

Date

Select State Pharmacy Council	(where presently registered)
Registration No. *
Registration Date *	* dd mm yyyy
Registered under Section (u/s)*

Name*

*
Write your name as it appears in your 10^th class mark sheet

Father's Name*

Don't write Shri/ Mr.

Mother's Name*

Don't write Smt./ Mrs.*

Date of Birth*

* dd mm yyyy
Select your date of birth as it appears in your 10^th class mark sheet

Age

Address*
(Permanent)

House No.

Street

Area

City

State

District

Pincode

Address*
(Present, for communication)

If your present address is same as permanent address, click on the check box, otherwise, write the full present address along with city, pin code.

House No.

Street

Area

City

State

District

Pincode

Domicile State*

Nationality

Landline Phone Number

Cell No. (Mobile No.)*

* *

Alternate Cell No. (Mobile No.)

email ID

Gender*

Caste*

Marital Status*

Residence Proof*

Residence Proof Details*

Aadhaar Card No.*

Matriculation (Class 10) Details*

Name of School

Place

State

District

Name of Board

Board City

Roll No.

Year of Passing

10+2 (Class 12) Details*

Name of School

Place

State

District

Name of Board

Board City

Name of Subjects*

(if any)

Roll No.

Year of Passing :

Pharmacy Qualification Details*

Pharmacy Course

	Select Specialization
	Select State
	Select Institution
	Name of Institution
	PCI Approval upto
	S. No.
	Institute Category
	City
	University / Board
	State
	City
	Year of Admission
	Email Id of College
	Year of Passing
	Final Year Roll No.
	Enrollment No.

Practical Training (Institution at which practical training undertaken)	Name of Center
	Drug License No.
	Address
	City
	State
	Training Period from - - to - - dd mm yyyy dd mm yyyy from to
	No. of Practical Training Hours per Day

	Pharmacy Training Pharmacist Name
	Registration No. of Pharmacist (at training center)
	Registered at State Council

Residence Details Starting from 10 Years before the First Registration upto till Date
Residence Period	from to
Address	(Maximum 200 characters )

Employment Details

(आप किसी भी क्षेत्र में कार्य कर रहे हो, Employment Details में उसका उल्लेख अवश्य करें।)

Employed/Self Employed Unemployed

	Employer Type Nil
	Name of employer (Write company/firm name)
	Employer Address
	Drug Licence No. (if applicable)
	Date of Joining - - dd mm yyyy
	Designation
	Place of Posting