(Appendix – 1)

AFFIDAVIT
(On Non-Judicial Stamp Paper)

1. I, Dr. _____________________________________________________________________ SELF ATTESTED

RECENT
S/o, D/o, W/o ______________________________________________________________ PHOTOGRAPH

2. Date of Birth (DD/MM/YYYY):

3. Residential Address of Faculty:

(a) Present..________________________________________________________________________

______________________________________________________________________________________

(b) Permanent .._________________________________________________________________________

______________________________________________________________________________________

4. Contact Details: Mobile No.__________________ Resi. Tel. No. with STD Code __________________________

Email ________________________________________________________________________

*5. Any one documents from 5a and 5b is mandatory:-

5a. Proof of Photo ID Document No. 5b. Proof of Residence Document No.
1. Passport 1. Passport
2. Voter ID Card 2. Aadhaar Card
3. Driving License 3. Voter ID Card
4. Aadhaar Card 4. Bill – Electricity /
Landline Phone
5. Regd.Rent Agreement
Note: - Original Documents are mandatory for verification. All Documents/Certified Translations, must be in English.

*6. Pan Card No. ________________________ Certified copy to be enclosed.

*7. Aadhaar Card No. ____________________ Certified copy to be enclosed.

*8. Qualifications:
Year & *Registration
Name of the
Month of No. of UG & PG
Degree Name of the Institution University Speciality State Dental
Passing with date of
Council
Renewal
B.D.S.

M.D.S.

Any
Other
*Enclosed certified copy of the State Council Registration renewed till date.

9. Present Designation: ____________________________________

10. Name and Postal Address of College/Institution: ___________________________________________________

_________________________________________________________________________________________

*11. Present Institute Appointment Order No. ___________________________________ Date _________________

(Signature of Faculty) (Signature of Dean /Principal)

Contd/….2
 –2 –

*12. Before joining present institution I was working at __________________________________________________

as _________________________________ and relieved on ___________________after Resigning/Retiring.

(i) Appointment Order No. ______________________________& Date _________of the previous appointment:

(ii) Relieving Order No. _________________________________& Date_____________

*13. TEACHING EXPERIENCE*

Position Name of Institution From To Total Experience

Tutor N/A

Lecturer/Asst.
Professor
Reader/Associate
Professor
Professor

Dean/Principal

* Less than one year teaching experience will not be considered. * Use separate box for each Institution.

*14. TOTAL SALARY DRAWN FROM THE COLLEGE IN THE LAST SIX (6) MONTHS
S.No. Month Amount Received Tax Deducted
1.
2.
3.
4.
5.
6.
(Last Six (6) months – Certified Copy of Bank Statement/Pass Book by the bank must be attached)

*15. TDS FOR THE LAST THREE FINANCIAL YEARS:

S.No. Financial Year TDS Paid

1.
2.
3.
(Copy of Form 16 generated from TRACES for last three financial years to be attached)

*16. DETAILS OF PUBLICATIONS:

S.No. Title of the Articles Journal Details Points

1.
2.
3.

Note: Submit certified clear Photocopies of all the documents mentioned in Serial No. 5, 6, 7, 8, 11, 12, 14 & 15 alongwith the Affidavit, Serial No. 13 & 16
to be submitted separately. All copies must be signed by the faculty member and counter signed by the Principal/Dean with date.

(Signature of Faculty) (Signature of Dean /Principal)

Contd/….3
 – 3 –

DECLARATION

1. I, Dr. _______________________________________ do hereby give an undertaking that I am working as

a full time salaried employee (as per UGC Norms) designated as _________________________ in the
Department of _____________________________________________________________________ at
__________________________________________________________________ (name of the college) on
all working days, working Hours from _____________ to ____________.

2. I am working as a Full Time/Part Time* faculty.

(*As per Rule 16 of DCI, Master of Dental Surgery Course Regulations, 2017)

3. I have not presented myself to any other Institution as a faculty in the current academic year for the purpose
of DCI Inspection.

4. I am not having private practice anywhere OR I am practicing at __________________________________

in the city of ____________________ and my days and hours of practice are ________________________
_____________________________________________________________________________________.

5. I, hereby, declare that the above information and documents provided by me are absolutely true, correct and
authentic to the best of my knowledge. In the event of any statement made in this declaration is found to be
incorrect or false I fully understand that I am liable for any necessary disciplinary/legal action.

Date: (Signature of the Deponent)

This is to certify that the information given by the above deponent is correct and nothing has been concealed 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.

Signature of Principal of the College Signature of the Chairman of the Trust

with seal and date with seal and date

Attestation by Notary Public/Oath Commissioner

CERTIFIED THAT THE DEPONENT
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

_____________________________________________________________________________________________________________________________________________________________

Counter Signature of the Deponent

(On the day of Inspection)

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.

(Signature of Inspector – 1) (Signature of Inspector – 2)

Dr. _________________________________________ Dr. _________________________________________

Date ________________________ Date ________________________

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