LORD SHIVA COLLEGE OF NURSING,

HAMIRGARH, MOONAK, DISTT. SANGRUR, PIN CODE - 148033

Appli!"i#$ F#%& '#% A(&i))i#$ i$ GNM* ANM


Name (IN BLOCK CAPITALS)
Fathers Name (IN BLOCK CAPITALS)
Mothers Name (IN BLOCK CAPITALS)
Annual income of arents from !s" ##################
all sources
$ate of Birth $a% Month &ear
A''ress for Correson'ence
Phone No" Fa( No"(if an%)
Permanent A''ress
Phone No" #################Fa( No"(if an%) ###########
Tic) !esi'ence Status Pun*a+ State Other State

Aca'emic ,ualifications
(-./0 'etails)
Examination
Board/
University
Roll No. Year Subject Marks
Max. Obtained a!e
Matric
10+1
10+2

-./-1 -./0 from Pun*a+ Outsi'e Pun*a+
Medical Non Medical Other
Photograph
U$(+%"!,i$- !$( pl+(-+ ./ "0+ !$(i(!"+23
a) I here+% certif% that the entries ma'e +% me in this form are correct to the +est of m% )no4le'5e 6 +elief an' I
ha7e not conceale' an% information in an% manner"
+) I a5ree to o+ser7e an' a+i'e +% all the rules an' re5ulations of the Institution an' 'urin5 the erio' of m%
stu'ies I 4ill not associate m%self 4ith an% acti7it% re*u'icial to the 'isciline of Institution"
c) I full% un'erstan' that for an% 7iolation or infrin5ement of these rules an' re5ulations1 'iscilinar% action can +e
ta)en a5ainst me +% the authorities 4hich ma% inclu'e cancellation of the can'i'ature"
') I certif% that I am not in7ol7e' in an% ille5al acti7it% an' no criminal case is en'in5 a5ainst me in an% court of
la4"
e) I am a4are that for articiatin5 in 8!a55in59 acti7ities1 I can +e e(elle' from this colle5e"
f) I un'erstan' that if at an% sta5e1 it is foun' that I ha7e ro7i'e' an% 4ron5 information to see) a'mission1 m%
a'mission shall stan' cancelle' automaticall% an' I shall ha7e no claim 4hatsoe7er1 on the seat or the 'ues
ai' to the Institution"
Thum+ Imression Si5nature of Can'i'ate
$ate
U$(+%"!,i$- ./ P!%+$"*G1!%(i!$
I certif% that m% 'au5hter:4ar' Ms""###############################################has su+mitte'
this alication 4ith m% )no4le'5e an' consent an' that I hol' m%self resonsi+le for her 5oo' con'uct an' her
maintenance an' timel% a%ment of fees an' other char5es 'urin5 the sta% at Institution" The entries ma'e +% her in
the A'mission Form are correct to the +est of m% )no4le'5e an' +elief"
Si5nature of Parent:;uar'ian
Name of Parent:;uar'ian
#####################

ENCLOSURES 2ITH APPLICATION FORM3
Matric or e<ui7alent certificate for $ate of Birth"
A co% of -.
th
1 -./-1 -./0 or e<ui7alent e(amination 4ith $etaile' Mar) Sheet"
Character certificate from school:colle5e (last atten'e')"
SC:ST:BC1 rural area certificate atteste' +% -
st
class ma5istrate"
An eli5i+ilit% mi5ration certificate for the can'i'ate 4ho has asse' from +oar':uni7ersit% other than Pun*a+
Boar' an' =ni7ersities" (If selecte'1 mi5ration certificate has to +e 'eosite' 4ithin -> 'a%s of a'mission)"
Pun*a+ 'omicile certificate"
?i5ht recent assort si@e hoto5rahs"
One self a''resse' stame' en7eloe"