School/College of Nursing P.O.Padhar, Dist. Betul-460005 (M.P) Phone: 07141-263500, 263590, and 263591 Ext: 291, 292, and 293. Application Form foranm/gnm/b.sc.nursing Admission (TO be filled in by the applicant in block letter) Student Profile: - I am Applying for course 1. Name : 2. Date of Birth:- / / Sex: 3. Age: years 4. Father Name: Passport size Colour photo To be attached here 5. Mother Name: 6. Permanent Address: Pin: 7. Contact No.(R): - (M): - 8. Religion: Caste:-ST/ SC / OBC / Gen/If other: 9. Marital Status: 10. Educational Qualification :- S.no Examination Passed Name of the School/Board Year/ Month % Marks / Grade Trial 1. 10 th 2. 12 th Additional Qualification Achievements
11. Church Affiliation: - 12. Give the name and address of two reference ( Must Not berelated ) 1. Name: 2. Name: Designation: Address: Mobile: Designation: Address: Mobile: General / ST / SC / OBC Category Quota :- Batch commencing on :- Application No :- Application received on :- Application fee paid :- Application status :- For office use only: Signature of Signature of Signature of Principal Parent/ Guardian Applicant Note:- 1. Age limit is 17 to 35 year. 2. Mark sheet & Certificate of 10 th & 12 th or pre University Degree are to be attested by a Gazetted officer. 3. If any misinformation will be lead to immediate rejection of candidate. 4. Reference letter from Pastor /Priest/ Principal. 5. Character Certificate from Principal of School/College last attends, with seal.
School/College of Nursing P.O.Padhar, Dist Betul-460005 (M.P) Phone: 07141-263500, 263590, and 263591 Ext: 291, 292, and 293. Application Form forpost Basic B.sc. NursingAdmission (TO be filled in by the applicant in block letter) -: Student Profile:- 1. Name: 2. Date of Birth: - / / Sex: 3. Age: years 4. Father Name: 5. Mother Name: 6. Permanent Address: Pin: 7. Contact No.(R): - (M): - 8. Religion: Caste:ST/ SC / OBC / Gen/If other: 9. Marital Status: Passport size Colour photo To be attached here 10. Educational Qualification :- Examination Name of the S.no Passed School/Board Year/ Month % Marks / Grade Trial 1. 10 th 2. 12 th Additional Qualification GNM 1 st year 1 2 GNM 2 nd year 3 GNM 3 rd year 4 GNM 4 th year Name Of Nursing Council: Registration no. Date of Registration:
Academic Achievements 11. Experience: No. Name of employer Designation From To Total 1 2 3 12. Church Affiliation: - 13. Give the name and address of two reference ( Must Not berelated ) 14. Name: 2. Name: Designation: Address: Mobile: Designation: Address: Mobile: For office use only: Category General / ST / SC / OBC Quota :- Batch commencing on :- Application No :- Application received on :- Application fee paid :- Application status :- Signature of Signature of Signature of Student Parent/ Guardian Principal
School/College of Nursing P.o.Padhar, Dist. Betul-460005 (M.P) Phone: 07141-263500, 263590, and 263591 Ext: 291, 292, 293. Scrutiny of documents: Required Documents: No. Name of documents: Enclosed Y/N 1. High School certificate 2. High School marksheet 3. 10+2 certificate 4. 10+2 mark sheet 5. Domicile certificate 6. Caste certificate 7. Affidavit for gap in the studies 8. transfer /migration certificate 9. Character certificate 10. 10 passport size photograph 11. Income certificate (for SC/ST/OBC) 12. Sponsorship certificate 13. Plastic file cover with 12 pouches 1. GNM 1 st year mark sheet 2. GNM 2 nd year mark sheet 3. GNM 3 rd year mark sheet 4. GNM 4 th year mark sheet 5. Nursing Council Registration 6. Reliving order (if working) If applying for Post Basic B.Sc. Nursing Student Sign
Declaration by Student I have carefully read the details regarding the admission to the Nursing Course. I declare that the information provided by me in this application is true and correct to the best of my knowledge. Should it be found that the information furnished is untrue in material particulars, I know that I am liable for criminal prosecution and will forgo the allotted seat; the decision of the school is final and binding. I am also aware that the school will not refund the fees either in full or in part, under any circumstances, if I intend to discontinue the course at any time after joining, I hereby undertake to pay the school fees and dues as application for the course. Place Date (Signature of the Application) Declaration by the Parent / Guardian (To be signed by the guardian only if both parents of the applicant are not alive) I hereby affirm that the information provided and enclosures submitted with application of my Son/ Daughter /Ward for admission to the nursing course is true & correct to the best of my knowledge. Should it be found that the information furnished is untrue in material particular, I know that I am liable for criminal prosecution and He / She will forgo for the allotted seat. I am aware that in all matters regarding His / Her admission to the course, the decision of the school is final and binding. I am also aware that the school will not refund the fees either in full or in part, under any circumstances, if my ward decides to discontinue the course at any time after joining, I hereby undertake to pay the school fees and dues for the remaining duration of course. Place Date Signature of the Parent /Guardian (If Guardian, Mention Relationship)
School/College of Nursing P.o.Padhar, Dist Betul-460005 (M.P) Phone: 07141-263500, 263590, 263591 Ext: 291, 292, 293. (Medical Checkup Report of Student) Name (In Capitals): Age: Sex: Religion: Father Name Any one in family has infectious contagious disease? Yes / No State who (relation to the candidate) Details of the disease/sickness Does the candidate have any disease? If Yes (give details): Menstrual History: Physical Examination Weight Height B.P.: Pulse Res. Heart: Lungs Abdomen Liver Spleen Teeth Nose Throat Skin Gland Vision Hearing Lab Investigation V.D.R.L Urine Analysis Stool Exam Sickling Test: Chest X-Ray HBsAg HIV Haemogram: Attached / Not Attached Any other problem: Doyou thing the Candidate is fit to take nursing training? Fit /Unfit.
To, The Principal School /college of Nursing,Padhar School/College of Nursing P.o.Padhar, Dist Betul-460005 (M.P) Phone: 07141-263500, 263590, 263591 Ext: 291, 292, 293. Subject: Allotment of Seat at School Hostel. Respected Madam I wish to reside in the school Hostel. Kindly allot a seat at Boy /Girl s Hostel. I solemnly declare that during my stay at the hostel I will abide by the rules & regulations of the school hostel in force and as modified thereafter or from time to time. I am aware that if any misbehavior against hostel rules will be done by me I will be removed from the hostel whenever declares by the authority. Home address to which any urgent communication may be sent. Phone No: Full Name: Signature: (In block Letter) Date of admission: Address of local guardian: Name: Address: Phone No.