Name*
(in block letters as in Matriculation Certificate)
|
*
|
Father's Name*
(CAPITAL LETTERS)
|
*
|
Mother's Name*
(CAPITAL LETTERS)
|
*
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| Photo*
|
*
scanned passport size photo with size
170px X 220px in .jpg format
|
| Date of birth* |
*
(from 10th certificate)
dd.mm.yyyy
|
| Place Of Birth* |
*
|
| Aadhar Number* |
*
|
|
Aadhar card File Upload*
|
*
in PDF formate
|
| Address* |
*
|
| District* |
|
| Mobile number* |
*
Enter a valid phone number
10 digits valid moblie number
|
| Gender* |
|
| Married* |
|
| Identy Proof* |
Type :
|
|
Upload ID Proof :
*
in PDF formate
|
| Employment details (if applicable)
|
|
Present
|
Name of organisation :
|
Address :
|
|
Period
|
|
|
|
Previous
|
Name of organisation :
|
Address :
|
|
Period
|
|
|
| Login Details
|
| Enter Password to Login (Minimum 6 Character)* |
*
|
| Re-Enter Password* |
*
|
Declarations:
- I hereby declare that I have not so far registered my name in any other State Pharmacy Council in India.
- I hereby declare that I am residing in the state of Haryana or carrying out the business of pharmacy or serving the profession of pharmacy in the state of Haryana. Hence this application is made for re-registration in the Haryana State Pharmacy Council.
- I hereby declare that information given in the application form is true and I understand that my application is liable to be rejected summarily or the registration is liable to be cancelled forthwith, u/s 36 of the Pharmacy Act, 1948 if the above information is proved to be false in any particular, at any stage.
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