REGISTRATION SLIP

. APPLICATION NUMBER
252390
:

POST APPLIED FOR : NURSES

CANDIDATE NAME : SANGEETHA A

GENDER : FEMALE

EMAIL
MOBILE NUMBER : 9655085370 MATHIALAGANERA@GMAIL.COM
ADDRESS :

AGE AS ON
DATE OF BIRTH : 05/05/1988 31 YEARS, 1 MONTHS, 26 DAYS
01.07.2019:

SPOUSE NAME
MARITAL STATUS : MARRIED MATHIALAGAN R
:

AADHAR CARD NUMBER : 4852 5560 8972 PAN NUMBER : NA

RELIGION: CHRISTIAN

ANTHONISAMY MOTHER'S
FATHER'S NAME: REJINAMARY A
S NAME:

PLACE OF
NATIONALITY: INDIAN NATCHIARKOIL
BIRTH:

CANDIDATE'S
PLACE OF
CANDIDATE'S PLACE OF BIRTH (DISTRICT): THIRUVARUR TAMIL NADU
BIRTH (STATE)
:

MOTHER TONGUE: TAMIL

TAMIL NADU
NURSES AND
MIDWIVES
DATE OF REGISTRATION IN TAMIL NADU NURSES AND
05/07/2009 COUNCIL 110235
MIDWIVES COUNCIL :
PERMANENT
REGISTRATION
NUMBER -RN :

TAMIL NADU NURSES AND MIDWIVES COUNCIL

114098
PERMANENT REGISTRATION NUMBER -RM :

BACKWARD NAME OF THE CONVERTS TO CHRISTIANITY

COMMUNAL CATEGORY :
CLASS - BC SUB CASTE : FROM SC(EXCEPT PARAVAR)

DATE OF ISSUE
CERTIFICATE NO.(SUB CASTE) : 5751238 23/06/2005
(SUB CASTE) :
 ISSUING AUTHORITY (SUB CASTE): TAHSILDAR

ISSUE TALUK
ISSUE DISTRICT (SUB CASTE): THIRUVARUR KUDAVASAL
(SUB CASTE) :

ARE YOU AN Ex-SERVICEMEN: NO

DEPARTMENTAL DISCIPLINARY ACTION PENDING IF

ANY AGAINST YOU? :

ARE YOU ELIGIBLE FOR RESERVATION FOR THE

DIFFERENTLY ABLED PERSONS AS PER THE G.O.(MS)
NO
No.20, WELFARE OF DIFFERENTLY ABLED
PERSONS(DAP.3.2) DEPARTMENT, DATED.20.06.2018:

ARE YOU A GOVERNMENT SERVANT : NO

2 145 A AKKARAI MADHA KOVIL ST, SERUKALATHUR , KODAVASAL

PERMANENT ADDRESS :
TK, THIRUVARUR, TAMIL NADU, 612604

2 145 A AKKARAI MADHA KOVIL ST, SERUKALATHUR , KODAVASAL

CORRESPONDENCE ADDRESS :
TK, THIRUVARUR, TAMIL NADU, 612604

Qualification Specification Year of Passing Whether studied Tamil as one of the subject
SSLC 2003 YES
HSC 2005 YES
NURSING DIPLOMA IN GENERAL NURSING AND MIDWIFERY 2009
OTHERS

First Choice Second Choice Third Choice

Examination Centre TIRUCHIRAPALLI CHENNAI MADURAI

Photo/Document
Photo - Uploaded Signature - Uploaded
SSLC Mark Sheet - Uploaded HSC Mark Sheet - Uploaded
Nursing Degree/Diploma Certificate - Uploaded Tamil Nadu Nurses and Midwives Council Registration Certificate - Uploaded

PAYMENT DETAILS :

Mode of Payment Payment Status Amount Paid Transaction Number Transaction Date
Online Success 700.00 723514463 21/02/2019 06:17:51 pm

I). I hereby declare that the particulars furnished by me in this application are true, correct and complete to the best of my knowledge and belief and
nothing has been concealed or suppressed. I also understand that in the event of any information being found false or incorrect or ineligibility being
detected before or after the examination or selection, I shall be liable for action taken by MRB.

II). I accept the undertaking & declaration of the candidate as in para 15A & 15B of the detailed notification and, I am not disqualified to apply for the
post.

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SUBMISSION OF THE FORM.

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