MALANKARA MAR THOMA SYRIAN CHURCH Mar Thoma Sabha Office, Tiruvalla-689 101, Kerala Ph: 0469-2630449, E-mail: [email protected]

APPLICATION FOR SPONSORSHIP FOR MSC DEGREE IN NURSING AT CHRISTIAN MEDICAL COLLEGE, VELLORE

1. Name of the applicant in full : 2. Address & Telephone No. :

3. Date of Birth : 4. Sex : 5. Father’s/Guardian’s Name, Occupation and address :

6. Relationship of Guardian : 7. Name of the parish : 8. Course applied for : 9. Year of passing B Sc. Nursing : 10. Marks obtained S S L C/C B S E/I C S E : Higher Secondary : Basic B.Sc. Nsg/B.Sc.Nursing : 11. Number of years spent to Complete the course : 12. Number of times appeared for Each examination S S L C/Higher Secondary : Pre Degree/Plus Two : Basic B Sc Nsg/Dipl.Nsg/B.Sc.Nsg. : If the candidate has failed, mention the subject : 13 Class and distinction obtained if any : 14 Whether the applicant has been a holder of merit scholarship. If so, name of the Scholarship and the merit : 15 (a)Was the candidate a sponsored student by the Mar Thoma Church for B.Sc.Nsg :

(b)If the candidate was sponsored student has she completed the bond? : 16 No.of years the candidate has served in any of the supporting mission hospitals after B Sc Nsg (including internship) please enclose a copy of the certificate of the Medical Supt where she has worked for at least 2 years Please enclose a Copy of the certificate of the Medical Supt. where she has worked : 17 Whether married or not : 18 Religious activities : 19 Family background of religious activities : 20 If the applicant is a communicant member, Certificate from the Vicar to be enclosed : 21 Whether prepared to serve after completing the course in any hospitals belonging to the Mar Thoma Church as directed by The Metropolitan or in any institutions as Directed by the Principal, CMC, Vellore for A period of two years : 22 CMC Application No : 23 Total annual income of the family :

Place: Date: Signature of applicant

Note:- Testimonials regarding: ability, character & conduct and interest in church activities and Membership in parish are to be enclosed. Attested copies of mark list should be attached to the application. Application duly filled up should reach the Sabha Secretary, Mar Thoma Sabha Office, Tiruvalla - 689101 on or before 05.01.2018 3pm.Application fee Rs.750/-(DD in favour of Sabha Secretary, drawn on Thiruvalla branch).