BALAJI INSTITUTE OF MEDICAL

SCIENCE & TECHNOLOGY

APPROVEDBYTHEGOVT.OFKARNATAKA&
KarnatakaNursingCouncil&IndianNursingCouncil
APPLICATION FORM GENERAL NURSING & MIDWIFERY
1.NameoftheCandidate----------------------------------------------------------------------------------
(InBlockLetters)
2.Father’s/Guardian'sName:---------------------------------------------------------------------------

3.Father’s/Guardian'sOccupation:---------------------------------------------------------------------

4.Father's/Guardian'sIncome:-------------------------------------------------------------------------

5.Sex:------------------------------- PHOTO

6.PostalAddressforCommunication---------------------------------------------
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Phone:STD.Code.-
7.PermanentAddress:--------------------------------------------------------------------------------------
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Phone:-
8.a.DateofBirth---------------------------------------
b.PlaceofBirth-------------------------------------

9.YearofPassingPUC/Equivalent:--------------------------------------

10a.HigherExaminationpassed 1.Regd.No-----------------------------
b.MediumofInstructioninPUC/PDCOre 2.Month&Year------------------------
quivalentExamination 3.MaximumMarks--------------------
4.MarksObtained---------------------

b.TotalPercentageinPCB -------------------------------------------------------------------

12.a.Religion--------------------------- b.Cast--------------------------------------

13.a.Nationality:---------------------- b.Domicilestatus------------------------

DECLARATIONBYTHEAPPLOCANTANDPARENT/GUARDIAN
DearSir,
IhavegonethroughtheCollegeProspectus,doherebypromisetoabidebyallrulesandregulationsnowi
nforceandthosetobemadefromtimetotime.Iknowthatthefeepaidbymeisnotrefundable,transferableora
djustabletootherpartsorsubjects.IrequestyoutoadmitmeasoneofthestudentofRoohiSchoolofNursing.
SignatureofParent/Guardian SignatureofApplicant

(MEDICAL EXMINATION)

Height----------------------Weight--------------------Sight:--------------------Teeth:-----------------

Lungs--------------------Vaccinated----------------Hearings-------------BloodGroup--------------

WeathertheCandidatehassufferedfromanyofthefollowing:

(a).T.B.-------------------------------------------------(b).RheumaticFever-------------------------
(c).Mental/NervousDisorder------------------------(d)VaricoseVeins-----------------------------
(e).Rheumatism----------------------------------------(f)CardiacDisease----------------------------
(g)Gynecologicalabnormalities--------------------(h)Dental-----------------------------------

ALLERGICTO:

REMARKS:
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Thisistocertifythat,IhaveexaminedMr./Miss.----------------------------------------
andthatHe/Shedoesnothaveanydiseaseconstitutionalweaknessorbodilyinfirmityinher/him.
Iconsiderher/himtobefittoundergotheabovementionedcourse.

Date----------------------
Place--------------------- Seal&Signature
ofMedicalPractitioner

Reg.No.

FOR OFFICE USE ONLY

ProvisionallyadmittedtotheaboveCoursefromtheAcademicyear200 -200

VerifiedOriginalCertificates
10thMarksCard
AdmissionNo. PUC/PDC/+2MarksSheet
TransferCertificate
MigrationCertificate
DateofAdmission: CertificateConduct
Secretary Principal