Application performa For

Admission to post basic B.sc (N) Course (2009-10) at

College of Nursing, G.G.Hospital, Jamnagar

1). Name of the applicant (in capital letters)

Surname ______________________________________

Name ______________________________________

Name of the father/husband ________________________

2).Sex:

Male Female

3).birth date : (as per School leaving certificate):

day month year

4): Age (on the day of 31 st augest 2009):

Years Months days

5) Marital Status:

marriad unmarried widow divorcee

6). Address:
Office: _____________________________________________________
_____________________________________________________
Telephone/fax no. (with STD code): _______________________
Residence: _________________________________________________
____________________________________________________
____________________________________________________
Telephone no. ____________ Mo. No. ____________________
7) Caste:
open Schedule Schedule S.E.B.C Physically
tribal Caste Disabled
8). Professional education :
A: General Nursing & Midwifery:

year Name of Year of Total Marks percentage attempt

the school passing Aggregate obtained
of nursing Marks
first
second
third
Forth
B: Any other professional education: (D.N.E.A./Diploma in P.H.N……etc)

course Name of the Years of Total Marks percentage attempt

institute passing aggregate obtained
Marks
(final years)

9) Details of professional experience

Sr.no Name of designation Experience Experience in Remarks

the From --- to- days months yrs
institute
1
2
3
4
5

10). Details of Registration to Gujarat nursing council:

Sr.no Title Registration no. Dated

1
2

Necessary Documents (certified Xerox) to attached with the Applicant

1. school leaving certificate.

2. mark sheet and certificate of H.S.C. or equivalent exam.

3. mark sheet of all years for general nursing & midwifery course.

4. mark sheet certificate and additional qualification certificate of GNC for

any other professional course (D.N.E.A/ Diploma in P.H.N… etc

5. registration certificate of diploma in general nursing & midwifery

6. experience certificate

7. Medical fitness Certificate

8. Self address 2 enevelopes with postage stamps affixed

9. certificate of caste

10. non- cremilayer certificate in case of reserved category, issued after : 1/4/2009
 Date: 20/08/2009

CERTIFICATE

This to certify that Mr.Alpesh champaklal shah Is working in Shri Sayaji

Rao General Hospital, Vadodara of Gujarat State health & Welfare
Organization as Male Staff Nurse. It is a 1500 bed hospital.

He has handled varies types of emergency work as well as time to time

nursing care as per requirements during his duty.

He has been working in services of government of Gujarat since 24-10-

2009 as male nurse and it is still continue.
He is very Sincere, Honest and hard working person. I wish him all
success in his future.
 ં
સમિત પ ક

એસ.એસ .હો પીટલ,વડોદરા ખાતે ફરજ બ વતા ે સી.શાહ ટાફ

ી અ પશ

નસ વગ-3 બ વે છે .. ઓ કોલજ
ે ઓફ નસ ગ, . . હો પીટલ, મનગર ખાતે

શૈ ણક વષ ૨૦૦૯-૧૦ થી બે વષનો પો ટ બે ક બી.એસ..સી.(નસ ગ) મા ં જોડાવવા

ઇ છે છે . તઓન
ે ે તે કોષમા ં જોડાવવા માટ સમિત
ં આપવામા ં આવે છે .

તાર ખ :

થળ :