ADMISSION FORM

INDIAN MEDICAL INSTITUTE OF NURSING

BIDHIPUR PHATAK, JALANDHAR- 144011
H.O.: 33, GURJAIPAL NAGAR, JALANDHAR
Email: iminursing@gmail.com

APPLICATION FORM FOR GNM, ANM

Sir,

I am desirous to seek admission in courses of your institution and submitting my

Bio-data as in the following:
1. Name of applicant...............................................................................................................
(in capital letters)
2. Applicants Father Name: ......................................................................................................
3. Applicant's Mother Name: ..............................................................................................................................
4. Full Permanent Address.................................................................................................................................
............................................................................................Phone.......................................................................
5. Correspondence Address: ............................................................................................................................
.....................................................................................Phone ......................................Mobile...........................
6. Name of the Medical course: ..................................................................................................................
7. Date of Birth .......................................................... 8. Nationality:...............................................................
9. Marital Status ...................................................... 10. Sex: .........................................................................
11. State if belong to SC/BC/ST: .................................................................................................................
12. Educational Qualification: ..........................................................................................................................
13. RN No. ___________, RM No. _____________, Dated _____________, Council ____________________
S. No. Exam Passed
Board/University
Year Total Marks Marks Obtained % age

14. Other Courses: ...........................................................................................................................................

15. Any extra Curricular Activity or any distinction in studies if obtained
16. Whether applied for admission to other institutions, different courses if so please give details...................

DECLARATION
I was born .........................................and I am eligible for admission as per minimum/ maximum age for admission. I
also hereby declare that I have filled the above form myself and the information submitted by me is correct. If any
information I have submitted shall be found false or that any fraudulent means have been used by me for seeking the
admission I shall be liable for any action and the authorities will have all rights to take any action against me. I further
declare that I shall strictly abide by the rules and regulations of the Institution.
Date...................................
Place.................................

__________________________
Parent's/Guardian's Signature

_______________________
Full Signature of Applicant

SELECTION/ADMISSION ORDER
Mr./Mrs./Miss...................................................................................................................................................................... is
admitted provisionally in the............................................................................. Course subject to payment of the
prescribed fee. His/Her candidature will remain provisional till............................................................................................
................................................................................................................................................................................................
Date: ................................

Auth. Signature

DECLARATION FROM APPLICANT AND PARENTS/GUARDIANS

Miss/Mrs./Mr. ........................................................................................................................................................................
Daughter/Wife/Son ................................................................................................................................................................
Resident of .............................................................................................................................................................................
Have sought admission ..........................................................................................................................................................
I do hereby declare
(1.) That if I will be admitted, I will abide by the rules and regulations of the Institution made by the other authorities
thereafter. (2.) That I hold my parents and myself responsible for the timely payments of all the dues i.e. tuition and
hostel fees and all the other service charges payable. (3.) That I agree to abide by the discipline of the Institute. (4) That
if at the end of the preliminary period of three months, the authorities decide that my work and conduct is not
satisfactory or have short of any of the essential qualities for the profession that I cannot be accepted then I agree to
discontinue my training/study, that I also understand that my admission may be cancelled if I have submitted Incorrect
or Incomplete Information to the Institute, in such case I agree that any fee paid by me shall not be refunded to me. (5) I
also agree that any breakage of equipments, materials etc. in the hostel/hospital/class/lab. Has to be borne by me. (6) I
agree to pay the full amount of the hostel and Institute fees if I leave the Institute before the completion of the course.
(7) That I have not paid donation for getting admission. (8) That I will not take part in or form any union, if I take part, I
may be restigated from this Institute. (9) That I will not drink any chemical/acid/drugs, if I do so, I will be responsible.
(10) That If I directly or Indirectly take part in any movement to create any type of disturbances during my stay in
Institute or hold any meeting in the Institute without the permission of the Director if I am guilty for unsatisfactory work
or for misconduct, in any way, then I agree that my name may be removed from the roll of the Institute or expelled as
may be decided by the authorities. (11) I fully agree that any charges once paid by me/parents/guardians are not
refundable in any circumstances. (12) If I leave the Institute for any reason whatsoever I will pay all the dues for the full
training period. (13) I fully understand that l have to work in various sections of the hospital, I will take care of my
chastity, modesty and womanhood. I will not indulge in any act, which may bring bad name to the Institution; I will be
fully responsible for my action and behaviour. (14) I assure you that I will not indulge in any behaviour or act that may
come under the definition of ragging. I will also not participate in or propagate ragging in any form. I will not hurt
anyone physically or psychologically or cause any other harm. If found guilty, I may be punished as per law. (15) We
have read the above statement carefully and understand the same and hereby signed it in full sense.

____________________________
Signature of the Parents/Guardians
with full name and Postal address.

__________________
Signature of Candidate