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Balaji Institute of Medical Science & Technology

This document appears to be an application form for admission to the General Nursing and Midwifery program at Balaji Institute of Medical Science & Technology. The application requests basic personal information from the applicant such as name, address, date of birth, family details, educational qualifications and medical examination results. It also includes declarations by the applicant and parent/guardian agreeing to abide by institute rules. If provisionally admitted, spaces are provided for admission number and date of admission along with verification of original certificates.

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Dev Kumar
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72 views3 pages

Balaji Institute of Medical Science & Technology

This document appears to be an application form for admission to the General Nursing and Midwifery program at Balaji Institute of Medical Science & Technology. The application requests basic personal information from the applicant such as name, address, date of birth, family details, educational qualifications and medical examination results. It also includes declarations by the applicant and parent/guardian agreeing to abide by institute rules. If provisionally admitted, spaces are provided for admission number and date of admission along with verification of original certificates.

Uploaded by

Dev Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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---------------------------------------------
-------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------

Phone:STD.Code.-
7.PermanentAddress:--------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
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:
---------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------

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

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