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VKNRL SCHOOL OF NURSING

PONKA GRANT, NUMALIGARH


GOLAGHAT, PIN- 785699, ASSAM
(A CSR INITIATIVE OF NRL)

APPLICATION FORM
Photo
Course Applied For : GNM
Session : 2017-18

INSTRUCTIONS:

(To be filled in BLOCK/capital letter only)

(Incomplete applications will be rejected)

1. Name of the applicant:..


.

2. Fathers Name/Legal Guardians Name: ....


..

3. Fathers/Legal Guardians Occupation with Official Address: .


4. Mothers Name: ..

5. Mothers Occupation with Official Address:


.

6. Date of Birth (DD/MM/YY): ..

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7. Age (as on 31.12.2017):

8. Sex: .

9. Marital Status: ..

10. Religion: .....

11. Caste: (SC/ST(H)/ST(P)/OBC/MOBC/Others): ..

12. Person with Disabilities: Yes / No (If yes enclosed evidence with percentage of disabilities
and details)

13. Permanent Address: Vill/Town/City: ..


P.O: . District: .
State: .. Pin: .
Telephone/ Contact no: .

14. Address of Correspondence: Name:


Relation:
Vill/Town/City: .........
P.O: District: ..
State: .. Pin: ..
Telephone/ Contact no: .

15. Details of Academic Records (HSLC onwards):

Sl. Examination Stream Name of University/ Year of Percentage Division


No. passed Institution Board Passing of total
marks
obtained
1. HSLC

2. 10+2

3. Any other
qualification
s i.e. ANM
etc.

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16. Extra-curricular Activities:

17. Language Proficiency: English/Hindi/Assamese/Any Other if, specify..

DECLARATION

I hereby, declared that the above statement


provided by me are true and complete to the best of my knowledge. If any information is found
to be incorrect or untrue at any stage, I shall be liable for the same and have no claim against
the cancellation and/or taking any other legal action as deemed fit by the authority.

.. ..
Name & Signature of the parents Name & Signature of the Student

Date: Date:

DOCUMENTS TO BE SUBMITTED WITH THE APPLICATION FORM

i. Recent Passport photograph (2nos.).


ii. Age proof Certificate from competent authority (HSLC Admit Card).
iii. Caste Certificate in case of SC/ST/MOBC Candidates and Non-Creamy Layer Certificate in
case of OBC candidates.
iv. 10+2 qualifying certificate & Mark sheets /ANM qualifying certificate and mark sheet.
v. Permanent Residential Certificate (PRC).
vi. For disabled candidates, a copy certificate issued by competent authority showing % and detail
of disability needs to be submitted.

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