Last Date 2rd July, 2011 Form No.

Rajasthan University of Health Sciences, Jaipur

Application Form
For AFFIX YOUR
RECENT
Post Basic B.Sc. Nursing (2 years) 2011-12
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 ¼fgUnh esa½

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

4. Mother’s Name

5. Date of Birth
mm dd yyyy

6. 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. 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.)

9. City

10. District

11. State

12. Pin Code

13. Telephone Number (With STD Code) Mobile No.

14. Fax No. (If any with STD Code)

15. E- mail Address (If any)

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 Total Max. Percentage

Obtained Marks
1st Year

2nd Year

3rd Year
Internship

3. Total Percentage of Marks Obtained: .

4. Working Experience (Please give details Chronologically)

Name of Period of Length of

S.No. Designation
Organisation Services Experience
From To Years Month

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

AFFIX YOUR
RECENT
Certified that Shri./Smt./Kumari ..................................................................
PHOTOGRAPH
Son/Daughter/Wife of Shri .............................................................................................. Duly signed by the
candidate and
is appointed on the post of Nurse Gr. –II on ...........................................................and
attested by
he/she has joined on ............................................................. as Nurse Grade –II he/ Gazetted Officer

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 born (not adopted) Son/Daughter of Shri/Smt. ......................................................... and belongs
to ................................................................. Cast by birth as notified as SC/ST/OBC/(OBC not in Creamy
Layer) Under presidential Order for the state of ................................................................................ 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 to certify that Shri/Kumari/Smt. ...................................................................................................

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 in support of educational qualification(s)

2. Experience certificate wherever required.

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