Application Post Basic Bsc Nursing Gujarat Alpesh

Application performa For Admission to post basic B.sc (N) Course (2009-10) at College of Nursing, G.G.Hospital, Jamnagar 1). Name of the applicant (in capital letters) Surname ______________________________________ Name

______________________________________

Name of the father/husband ________________________ 2).Sex: Male

Female

3).birth date : (as per School leaving certificate): day

month

year

4): Age (on the day of 31 st augest 2009): Years

Months

days

5) Marital Status: marriad

unmarried

widow

divorcee

6). Address: Office: _____________________________________________________ _____________________________________________________ Telephone/fax no. (with STD code): _______________________ Residence: _________________________________________________ ____________________________________________________ ____________________________________________________ Telephone no. ____________ Mo. No. ____________________ 7) Caste: open Schedule Schedule S.E.B.C tribal Caste 8). Professional education : A: General Nursing & Midwifery: year first second third Forth

Name of Year of Total the school passing Aggregate of nursing Marks

Marks obtained

percentage

Physically Disabled

attempt

B: Any other professional education: (D.N.E.A./Diploma in P.H.N……etc) course

Name of the institute

Years of passing

Total aggregate Marks (final years)

Marks obtained

percentage

attempt

9) Details of professional experience Sr.no

Name of the institute

designation

Experience From --- to-

Experience in Remarks days months yrs

1 2 3 4 5 10). Details of Registration to Gujarat nursing council: Sr.no

Title

Registration no.

Dated

1 2

Necessary Documents (certified Xerox) to attached with the Applicant 1. school leaving certificate. 2. mark sheet and certificate of H.S.C. or equivalent exam. 3. mark sheet of all years for general nursing & midwifery course. 4. mark sheet certificate and additional qualification certificate of GNC for any other professional course (D.N.E.A/ Diploma in P.H.N… etc 5. registration certificate of diploma in general nursing & midwifery 6. experience certificate 7. Medical fitness Certificate 8. Self address 2 enevelopes with postage stamps affixed 9. certificate of caste 10. non- cremilayer certificate in case of reserved category, issued after : 1/4/2009

Date: 20/08/2009

CERTIFICATE

This to certify that Mr.Alpesh champaklal shah Is working in Shri Sayaji Rao General Hospital, Vadodara of Gujarat State health & Welfare Organization as Male Staff Nurse. It is a 1500 bed hospital. He has handled varies types of emergency work as well as time to time nursing care as per requirements during his duty. He has been working in services of government of Gujarat since 24-102009 as male nurse and it is still continue. He is very Sincere, Honest and hard working person. I wish him all success in his future.

ં સમિત પ ક

એસ.એસ

.હો પીટલ,વડોદરા ખાતે ફરજ બ વતા

ે સી.શાહ ટાફ ી અ પશ

ે ઓફ નસ ગ, . . હો પીટલ, નસ વગ-3 બ વે છે .. ઓ કોલજ શૈ

મનગર ખાતે

ણક વષ ૨૦૦૯-૧૦ થી બે વષનો પો ટ બે ક બી.એસ..સી.(નસ ગ) મા ં જોડાવવા

ે ે તે કોષમા ં જોડાવવા માટ સમિત ં ઇ છે છે . તઓન આપવામા ં આવે છે .

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