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Form preview Lee county declaration domicil... State of Florida Declaration of Domicile To the Clerk of the Circuit Court of Lee County This is my Declaration of Domicile in the State of Florida that I am filling this day in accordance and in conformity with Section 222. 17 of the Florida Statutes. I hereby declare that I reside in and maintain a place of abode at Number and Street Lee City Zip County Date You Became a Resident Which place of residence I recognize and intend to maintain as my permanent home and if I maintain another place or place of above in some other state or states I hereby declare that my above-described residence and abode in the state of Florida constitutes my predominant and principal home. And I intend to continue it permanently as such. I am at time of making this declaration a bona fide resident of the State of Florida* I formerly resided at I maintain another home at Address Number and Street Address City State Zip and County Date Signature Print Name County of Lee The foregoing instrument was acknowledged before me this day of 20 Identification type of ID produced Notary Public State of Florida Linda Doggett Clerk of Circuit Court Print type or stamp Commissioned name Seal. 17 of the Florida Statutes. I hereby declare that I reside in and maintain a place of abode at Number and Street Lee City Zip County Date You Became a Resident Which place of residence I recognize and intend to maintain as my permanent home and if I maintain another place or place of above in some other state or states I hereby declare that my above-described residence and abode in the state of Florida constitutes my predominant and principal home. And I intend to continue it permanently as such. I am at time of making this declaration a bona fide resident of the State of Florida* I formerly resided at I maintain another home at Address Number and Street Address City State Zip and County Date Signature Print Name County of Lee The foregoing instrument was acknowledged before me this day of 20 Identification type of ID produced Notary Public State of Florida Linda Doggett Clerk of Circuit Court Print type or stamp Commissioned name Seal.
Form preview Mci declarationform I have not presented myself to any other Institution as a faculty in the current academic year for the purpose of MCI assessment. am not having private practice anywhere OR practicing at hours of practice are to. Complete details with regard to work experience has been provided nothing has been concealed by me. It is declared that each statement and/or contents of this declaration and /or documents certificates submitted along with the declaration form by the undersigned are absolutely true correct and authentic. In the event of any statement made in this declaration subsequently turning out to be incorrect or false the undersigned has understood and accepted that such misdeclaration in respect to any content of this declaration shall also be treated as a gross misconduct thereby rendering the undersigned liable for necessary disciplinary action including removal of his name from Indian Medical Register. Issued by. Without Photo ID Declaration form will be rejected and will not be considered as teaching faculty 1. e i. Present Designation 1. e i a Certified copies of present appointment order at present institute attached. Department College 1. e iv. City Nature of appointment Regular / Contractual. 1. f Residential Address of employee 1. g Have you undergone Training in Basic Course Workshop at MCI Regional Centre in MET or in your college under Regional Centre observership Yes No If yes give details. NAME OF THE COLLEGE I II III IV Date of Assessment Accepted YES/NO/ABSENT Name of the Assessor Signature of Assessor DECLARATION FORM 2015 2016 - FACULTY 1. a Name. 1. b Date of Birth Age 1. c Recent Passport size photo of the Employee Signed by Dean / Principal of the college. 1. d Submit Photo ID proof issued by Govt* Authorities Photo ID submitted Passport copy / PAN Card / Voter ID / Aadhar Card PHOTOGRAPH TO BE COUTERSIGNED BY THE DEAN/PRINCIPAL Number. Issued by. Without Photo ID Declaration form will be rejected and will not be considered as teaching faculty 1. e i. Present Designation 1. e i a Certified copies of present appointment order at present institute attached* Department College 1. e iv* City Nature of appointment Regular / Contractual* 1. f Residential Address of employee 1. g Have you undergone Training in Basic Course Workshop at MCI Regional Centre in MET or in your college under Regional Centre observership Yes No If yes give details. Name of MCI Regional Centre where Training was done/If training was done in college give the details of the observer from RC Date and place of training 1. h Copy of Passport /Voter Card / Electricity Bill /Telephone Bill / Aadhar Card attached as a proof of residence. 1. i Contact Particulars Tel Office with STD code Tel Residence with STD code E-mail address Mobile Number 1. j Date of joining present institution as Joining report at the present institute attached* Qualifications College University Year Registration No* of UG PG with date Name of the State Medical Council MBBS MD/MS DM/M.

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