Registration

Personal Details
Name* (Same as in the SSLC Certificate)
Father'sName*
Gender*	Male Female Transgender
Place Of Birth*
Date Of Birth*
Blood Group*
Address*
Pincode*
State*
District*
Nationality*
Phone Number (with STD code)
Mobile Number*
Email Id*
Aadhaar Id*
Upload Your Color Photo*	[Width:150px Height:200px Max Size:30Kb Allowed Extension: jpg,jpeg]
Upload Your Signature*	[Width:150px Height:100px Max Size:30Kb Allowed Extension: jpg,jpeg]
Whether transfer from other state?

Educational Qualification Details
Select State	Name of University		Select Course	Name and Address of Institution

Certificate Number	Certificate Date	Certificate Type	Year OF Passing	Course Period

Upload Your Course Complete Certificate*		[Width:600px Height:800px Max Size:100Kb Allowed Extension: jpg,jpeg]		Upload Your Course Degree Certificate*	[Width:600px Height:800px Max Size:100Kb Allowed Extension: jpg,jpeg]
Name of the Pharmacy Council		Register Number		Register Date

Are You Resident Of Kerala		Yes No
Are You Doing Business In Kerala		Yes No		Produce Relevant Documents For Proving
Transfer Details
State*		KERALAMAHARASHTRATAMILNADUOthers
DD Details
DD Amount* Rs
Training Details (Mandatory for D.Pharm Holders)
Training State		Kerala Others States
Name of Training institution
Training Period
Details of Trainer
Payment Details
Amount*	Rs	Payment Mode*		Payment Through*
NRDS Declaration
I hereby agree that the amount of Rs. 1000/- (is for 10 years) for Voluntary Non-refundable deposit for renewal fee is also included in the amount of Rs. 3100/- I paid in favour of the Register, Kerala State Pharmacy Council, Thiruvananthapuram-35. In further, if due to some reasons this amount become inadequate to cover my renewal fee, I shall remit such additional amount as you may deem fit under section 34(1) of the Pharmacy Act 1948.

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