Pharmacy Council Registration Form
 * Marked Fields Are mandatory
Personal Details
Applicant Name* *
Father Name *
Mother Name *
Gender *
Date Of Birth (DD/MM/YYYY) *
Place Of Birth *
Mobile Number * Email Id *
Nationality * Domicile *
Residential Address
Address * Pincode *
State * District *
Permanent Address (Check If Same As Residential Address )
Address * Pincode *
State * District *
Educational Qualification Details
ExamBoard/UniversityRoll NumberPercentage (00.00)Year Of Passing
*
*
*
Training Details (Mandatory In Case Of D.Pharma)*
S.NoQualification With The Years In Which AquiredName Of Examining Which AwardedInstitution Where TrainedTraining On Date (DD/MM/YYYY)Traning End Date (DD/MM/YYYY)  
1
Hours Of Training (Mandatory In Case Of D.Pharma)*
Total Hours  Hrs Dispensary Hours  Hrs
Employed In Or Attached To Government Of State Aided Institute*
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