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Delhi Nursing Council One
A.B. College Nursing Building, L. N. Hospital, Photograph
New Delhi – 110002
Self-Attested
Application Form For Re-Registration
1. Surname…………………...... .First Name …………………...... Middle Name ………..................
(Write in capital Letter)
2. Father’s Name …………………………………………………………………………….…………………… ………………
3. Mother’s Name …………………………………………………………………………….………………………………………
4. Husband’s Name …………………………………………………………………………..……………………………………..
5. Gender Female Male 6. Marital Status Single Married
th
7. Date of Birth: …………………………….................................... (Attach copy of 10 Certificate).
8. Place of Birth: ……………………… 9. Nationality: ………………………10. Email Id ………………………….........
11.Present Address .....................................................................................................................................................
…………………………………………………………………………………...........Phone No.:……….............................
12. Permanent Address ..............................................................................................................................................
………………………………………………………………………………….....................:..........................................
13. General Qualification:…………………………………………………………………………………..............................
14. Name & Address of the Institution where nursing education was obtained….……................................................
…………………………………………………………………………………....................................................................
15. Programme of study completed (B.Sc./GNM/ANM/MPHW(F)/LHV/Health Supervisor) ……………………..…….
a. Date of Joining: ………………………........................... b. Date of Completion ………………….……………….
16.1 Name & Address of the Examining Body ..........................................................................................................
16.2 Date of Qualifying Examination…….../…......../.……. ( DD/MM/YYYY ) Roll No: ..........……………………..
17.1 Name of the Nursing registration Council with which registered already .......................................................
…………………………………………………………………………………..............................................................
17.2. Registration No. RN/RM …………………………… Date of Removal from register (if any) ....../........../.......
17.3 Date of reinstatement …………………............... Higher Professional Qualifications....………………….…
18. Name & Address of the Employer ( if working presently ) .................................................................................
……………………………………………………………………………………………………………………………………
I hereby declare that the information given above is true to the best of my knowledge and that there are no
instances of adverse professional conduct against me that could render me ineligible for registration as
Registered Nurse / Registered Midwife / MPHW (F) / LHV with Delhi Nursing Council.
Date........................... Place .............................. Signature Of Applicant ....................................
P.T.O
For Office Use Only
Application Checked by .......................
Registration fee paid Vide receipt No......................................................... Date ......../...../........ Registration
Number Alloted ........................................................................................................... Date ............ ...............
Place............................
Signature of Registrar
