Malwa College of Nursing

Phone: 01635 – 228188 MALWA COLLEGE OF NURSING (Only for girl students) (Recognized by: Punjab Govt., Punjab Nurses Registration Council, Chandigarh & Indian Nursing Council, Delhi and affiliated to Baba Farid University of Health Sciences, Faridkot) Faridkot Road, KOTKAPURA – 151204 (Punjab) Affix APPLICATION FORM FOR ADMISSION TO passport Post Basic B.Sc.(N) - 2 Years’ Degree Course size photo 1. Marks obtained in GNM Max. Marks Marks obtained 2. Registration No.with PNRC, Chandigarh : As Registered Nurse:__________As Registered Midwife:_________ 3. Category Name (Gen/SC/BC/NRI/Physically handicapped (PH)/J&K) 4. Name (BLOCK LETTERS) 5. Father’s Name (BLOCK LETTERS) 6. Mother’s Name (BLOCK LETTERS) 7. Annual income of parents from all sources Rs._______________ 8 Date of birth Day Month Year 9 Addresses for Correspondence: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Cell/Telephone No.___________________(Fax No., if any)________________ 10 Permanent Address: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Cell/Telephone No.___________________(Fax No., if any)________________ 11 Tick Residence Status Punjab State Other State 12. Particulars of qualifying examinations (GNM) (attach attested photocopies) Exam. Univ./ Session Roll No. Marks Percentage passed Board (Month/Year) obtained GNM 13. Particulars of working experience, if any, after passing GNM course (Attach experience certificate) Name of College/Institute/ Designation Working Experience Total Remarks Hospital From To period (mm/dd/yy) (mm/dd/yy) 14. 10+1 and 10+2 from Punjab(Tick ) Outside Punjab FULL Signature of the candidate 15. Undertaking and pledge by the candidate:- I solemnly declare that all the facts stated above are true and correct. In case any information if found incorrect at any state, my candidature may be cancelled and I shall have no claim whatsoever against the College or the University, I pledge to abide by the rules and regulations of the institution and the University as given in the Prospectus and to observe the Code of conduct given therein. I am joining this College with the express permission of my father/guardian. I have noted that my admission is PROVISIONAL subject to registration by the Baba Farid University of Health Sciences, Faridkot. FULL Signature of candidate Date:___________________ 16. Undertaking by Parent/Guardian:- I certify that my daughter/ward Ms______________________________ has submitted this application with my knowledge and consent and that I hold myself responsible for her good conduct and her maintenance and any payment of fee during the stay at College or even she leave the College in midstream. The entries made by her in the Admission Form are correct to the best of my knowledge and belief. Signature of Parent/Guardian Date_______________ Name of Parent/Guardian_______________ CHECKLIST OF ENCLOSURES (Attested copies of the following certificates) Checked by: Candidate College official i) Completion Certificate from the Head of the Institute from where passed the GNM examination (Form No.1) ii) Registration Certificate with PNRC, Chandigarh iii) Detail Marks Card 10+1 iv) Detail Marks Card 10+2 v) Matric or equivalent certificate for date of birth vi) Detail Marks Card 3rd Year GNM examination vii) Certificate in support of claim under reserved category as per specimen given in prospectus (Form N.8 or 9) viii) Residence Certificate ix) Gap year affidavit in original (Annexure I) x) Affidavit in original (not availed any Residence benefit in any other state) (Annexure II) xi) Experience certificate, if any **** .

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