Application Form #.

__020___

APPLICATION FORM IN GENERAL NURSING, TRAINING AT S.O.N. FEDERAL GOVERNMENT POLYCLINIC (PGMI) ISLAMABAD
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Full Name_TABINDA GHAFOOR CHUGHTAI__ Name of Father _ABDUL GHAFOOR GHUGHTAI Date of Birth 08.10.1993 Age: 17 Years 10 Months Religion __ISLAM__ Place of Birth ISLAMABAD_ Nationality __PAKISTANI___ Domicile PUNJAB_(GUJRANWALA)

National Identity Card # ______N.A._______

Marital Status:- _____Unmarried_________ Telephone #_051-9215095, 0333-5199480 District Gujranwala.____

Temporary Address_3/1-E, St. 49, F-6/4, ISLAMABAD

Permanent Address Village & P/O Kotjaffar, Tehsil Wazirabad,

_____________________________________________Telephone # _________________________

ACADEMIC QUALIFICATION S. # Examination Year Passed Matriculation 2010 01

Grade / Division 518/1050 D

2nd Div.
02 F.A . Part-I 2011 Result awaited

School/College / Board / University Federal Board of Intermediate & Secondary Education, Islamabad. Federal Board of Intermediate & Secondary Education, Islamabad.
Dar-ul-Aloom Mahmoodia Tehfeezul- Quran, G-10/2, Islamabad. 63 Biology 78

05

Any other Hifz-ul-Quran

2007

85/100
Physics

A+

Marks obtained in Science Subjects

61 Chemistry

Name and address of hospital/Institute, if worked previously?

NO

I hereby solemnly declare that:The information given above in the admission form is true/correct to the best of my knowledge and belief. I have no objection if my daughter joins the Nursing Training in this School.

Signature of Parents _____________________ Date:- ___12.08.2011____ Signature of Candidate ) _______________

MAILING ADDRESS 3/1-E, St. 49,

F-6/4, ISLAMABAD_

Telephone # 051-9215095, 0333-5199480

NAME OF PERSON TO BE NOTIFIED IN EMERGENCY NAME

ABDUL GHAFOOR CHUGHTAI_ Relationship __FATHER___

Address _3/1-E, St. 49,

F-6/4,

ISLAMABAD_ Telephone #_051-9215095 , 0333-5199480

Attached Attested Photo Copies of:a. Form B NADRA b. Domicile Certificate of Father c. Character/Provisional Certificate d. Matriculation & Hifz-ul-Quran certificates. e. National Identity Card of Father. _________________________________________________________________________________

RECEIPT
Received form No. ________020__________ from Miss TABINDA GHAFOOR CHUGHTAI

For ______General Nursing Training__________ Signature/Stamp ___________________

APPLICATION FORM
SCHOOL OF NURSING PAKISTAN INSTITUTE OF MEDICAL SCIENCES ISLAMABAD
Application Form #. __240___

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PLEASE READ ENTIRE FORM CAREFULLY THE FORM MUST BE COMPLETED IN TYPE OR PRINT IN BLOCK LETTERS INCOMPLETE APPLICATION FORM SHALL NOT BE ENTERTAINED
Full Name_TABINDA GHAFOOR CHUGHTAI_ Name of Father _ABDUL GHAFOOR GHUGHTAI Date of Birth 08.10.1993 Place of Birth ISLAMABAD_ Domicile PUNJAB_(GUJRANWALA) Religion __ISLAM__ Nationality __PAKISTANI___ National Identity Card # ______N.A.______ Marital Status:- _____________Single _______________ Present Address_3/1-E, St. 49, F-6/4, ISLAMABAD Telephone #_051-9215095, 0333-5199480 District Gujranwala.____ Permanent Address Village & P/O Kotjaffar, Tehsil Wazirabad,

_____________________________________________Telephone # _________________________

ACADEMIC QUALIFICATION S. # Examination Year Passed Matriculation 2010 01

Grade / Division 518 Marks D

02

F.A . Part-I

2011

Result awaited

School/College / Board / University Federal Board of Intermediate & Secondary Education, Islamabad. Federal Board of Intermediate & Secondary Education, Islamabad.
Dar-ul-Aloom Mahmoodia Tehfeezul- Quran, G-10/2, Islamabad.

05

Any other Hifz-ulQuran

2007

85/100

A+

NAME OF PERSON TO BE NOTIFIED IN EMERGENCY NAME

ABDUL GHAFOOR CHUGHTAI_ Relationship __FATHER___

Address _3/1-E, St. 49,

F-6/4,

ISLAMABAD_ Telephone #_051-9215095 , 0333-5199480

Have you attended any other School of Nursing?

NO

If yes attach leaving Certificate.

Attached Attested Photo Copies of:a. b. c. d. e. Form B NADRA Domicile Certificate of Father Character/Provisional Certificate Matriculation & Hifz-ul-Quran certificates. National Identity Card of Father.

_________________________________________________________________________________

RECEIPT
Received form No. ________240__________ from Miss TABINDA GHAFOOR CHUGHTAI

For ______General Nursing Training__________ Signature/Stamp ___________________

DECLARATION
I hereby solemnly declare that:The information given in the admission form is correct to the best of my knowledge and belief and if any thin is found in correct; the School of Nursings Administration will have the right to cancel my admission.

Date:- ___12.08.2011____

Signature of Candidate ________________________

Signature of Parents _____________________

MAILING ADDRESS

3/1-E, St. 49, F-6/4, ISLAMABAD Telephone # Res. 051-9215095 Cell. 0333-5199480 Off. 051-9209449