APPLICATION FOR REGISTRATION
Diploma in General Nursing and Midwifery [Outside]
Name of the applicant :
Permanent postal Address :
Date of Birth :
Nationality :
State :
District :
Sex : Male Female
Father's Name :
Upload Recent Passport size Photograph :
State whether the application is for registration as Nurse / Midwife / A.N.M.
Nurse
Midwife
A.N.M
Name of the Hospital / Nursing School / Health Workers School where trained
Period of training (From-To) Month & Year :
Session of Examination (Month & Year) :
Language in which trained :
Name of the body (Council/Government) which awarded the qualification :
DD / Receipt Number :
DD / Receipt Amount :
DD / Receipt Date :
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Declaration
I hereby accept that the statements made in the form are true to the best of my knowledge and belief and that I am free from the disqualifications mentioned in Section 6 of the Nurses & Midwives' Act 1953, as amended and promise in the event of my being registered and in consideration there of to be bound by and to conform in all respect to the rules, regulations etc., framed by the council from time to time in force.