Last Date 2rd July, 2011

Form No.

Rajasthan University of Health Sciences, Jaipur

Application Form
For
Post Basic B.Sc. Nursing (2 years) 2011-12

AFFIX YOUR
RECENT
PHOTOGRAPH
Duly signed by the
candidate and
attested by
Gazetted Officer

Candidate's Signature
1
.

Name of the Candidate (Leave one box empty between First Name/Middle Name and Surname)

2
.

vkosnd dk uke fgUnh esa

3
.

Father's/Husband Name (Strike out whichever is not applicable)

4
.

Mothers Name

5.

Date of Birth

mm
6
.

dd

yyyy

Which Category you belong (SC/ST/OBC/SBC/General) ?

(SC/ST/OBC/SBC candidates must attach an attested copy of the caste
certificate) OBC/SBC certificate should be issued on or after 01-04-2011

7.

Nationality (Write the relevant code in the box if other please specify:
(A) Indian 01
(B) Others 02

8.

Whether Physically Handicapped : (Write the relevant code in the box)

(A) Yes 01
(B) No 02

9
.

9.

Address for Correspondence (Do not give Post Box No. Leave a blank box between each
unit of address like House No., Street Name, P.O., etc.)

City

10.

District

11.

State

12.

Pin Code

13.

Telephone Number (With STD Code)

14.

Fax No. (If any with STD Code)

15.

E- mail Address (If any)

Mobile No.

16. Professional Qualification- General Nursing or General Nursing & Midwifery (Tick
mark accordingly) :

(a) Name of Registration Council:(b) Registration No.

(i) Registered Nurse
(ii) Registered Midwife

:...................................................
:...................................................

2. Marks Obtained in General Nursing or General Nursing & Midwifery:

Name of Institute :...................................................................................................
Years

Total Marks
Obtained

Total Max.
Marks

Percenta
ge

1st Year
2nd Year
3rd Year
Internshi
p
3. Total Percentage of Marks Obtained:

4. Working Experience (Please give details Chronologically)

S.No
.

Name of
Organisation

Designation

Period of
Services
Fro
To
m

Length of
Experience
Year Mont
s
h

Total Experience ........................... Years .................. Months

DECLARATION BY APPLICANT

I hereby declare that I have read and understood the conditions of

eligibility for the programme for which I seek admission. I fulfill the
minimum eligibility criteria and I have provided necessary information in
this regard. In the event of any information being found incorrect or
misleading, my candidature shall be liable to cancellation by the
University at any time and I shall not be entitled to refund of any fee paid
by me to the University.

Date

Signature of

Candidate

CERTIFICATE FOR IN-SERVICE CANDIDATE

Certified
Shri./Smt./Kumari

..................................................................

Son/Daughter/Wife

of

Shri

is

..............................................................................................

appointed

on

on

...........................................................and

on

AFFIX YOUR
RECENT
PHOTOGRAPH
Duly signed by the
candidate and
attested by
Gazetted Officer

that

the

post

of

.............................................................

Nurse
as

Nurse

Gr.

II

he/she
Grade

has
II

he/

joined
she

has

completed........................................Yrs......................... Months............................. days in

regular service after appointment as Nurse Gr. -II

Date .......................200

Signature of Director/
Additional Director
Medical and Health Services Govt. of Rajasthan,

Jaipur

FORMET OF CERTIFICATE REGARDING SC/ST/OBC/SBC

(This certificate must be signed by an Officer not below the rank of District
Magistrate/Additional District Magistrate/Sub-Divisional Magistrate/Tehsildar of which the
candidate is a bonafide resident).
I

............................................................................

certify

that

Shri/Kumari/Smt. ................................. is
(Name of the
candidate)

the

natural

Shri/Smt.

born

(not

adopted)

Son/Daughter

.........................................................

and

of
belongs

to ................................................................. Cast by birth as notified as SC/ST/OBC/(OBC

not

in

Creamy

Layer)

of

Under

presidential

Order

for

the

state

................................................................................

District ............................................................................

Court Seal
Dated : ................................200

..................................

...........................

Signature of the

Distt. Magistrate

Addl. Distt.

Magistrate/S.D.M./Tehsildar

FORMET OF CERTIFICATE REGARDING DISABLED (PHYSICALLY

HANDICAPPED) CANDIDATE
(Only for Authorized Medical Board)

This

is

Shri/Kumari/Smt.

to

certify

that

...................................................................................................

Son/Daughter of Shri/Smt. .......................................................................................... Is a

Disabled

(Physically

Handicapped)

candidate

and

he/she

has ...............................................................................................................
.................................................................. (Mention Disablility).

Dated ..............................200

Competent

Authority
(With Official Seal)

Template for Envelop

APPLICATION FORM FOR POST BASIC B.Sc. (N.)

LAST DATE : 2rd July, 2010

To,

The Convener, Post Basic B.Sc. Nursing 2011-12

Rajasthan University of Health Sciences

Kumbha Marg, Sec. 18, Pratap Nagar, Jaipur - 302 033

From :
Name: _______________________________________________
Father Name: _________________________________________
Complete address : ____________________________________
_____________________________________________________
Phone : ______________________________________________
Cell No : _____________________________________________
E-mail : ______________________________________________

Note: - This form will not be accepted after 5.00 P.M. of 02nd July,
2011

Tick the relevant boxes

Affixed photograph and enclosed the following attested copies:
1.
Certificates
qualification(s)

in

support

of

educational

2. Experience certificate wherever required.

3. Category (SC/ST/OBC etc.)