A.

R NO :
(To be assigned by the Selection Committee Office)
ADMISSION TO POST BASIC B.Sc, ( Nursing ) COURSE 2014-2015 SESSION
APPLICATION FORM
SELECTION COMMITTEE, DIRECTORATE OF MEDICAL EDUCATION
---------------------------------------------------------------------------------------------------------------------------------
1. Name in Block Letters
(Initial at the end ) : .

2 . Address for Communication :

..





..

PIN CODE ... 4. Sex : (Encircle a code)

Phone / Mobile No. :


3. Name of Parent / Guardian : .. .. 5. Nationality : (Encircle a code)



6. Nativity : 6 a. Details of Education:
(Encircle a code) (Encircle a code whichever is applicable)








7. Date of Birth :



8. Community ( Encircle a code )


9. Name of the Caste:

10. Caste Code.
Refer list of Communities
( For OC use code 500 )


11. Religion : 12. Mother Tongue :







DD No Name of
Bank
Date Amount

MALE FEMALE
1 2
INDIAN OTHERS
1 2
TN OTHERS
1 2
Studied HSC (+1 & +2)
& Dip. Nursing in TN
Studied HSC (+1 & +2)
& Dip. Nursing in other
state
1 2
DATE MONTH YEAR



OC BC BCM MBC/DC SC SCA ST

1

2

2A
3

4

4A

5




SPACE FOR
PHOTOGRAPH WITH
NAME AND DATE
( TO BE ATTESTED
BY GRADE A / B
OFFICERS OF
CENTRAL / STATE
GOVERNMENTS)
1

13 a)

(b) Marks obtained in the Midwifery / Psychiatry
Examination of Diploma in Nursing

(c) Number of attempts in the final year
Diploma in Nursing Examination :

14. a. Date of passing Diploma in Nursing : ....

b. Total number of completed years after
passing Diploma in Nursing as on : ..
31.05.2014
15. Nursing Council Registration number :
Nurse

Midwifery

16 MARKS IN THE HSC EXAM ; -


SUBJ ECT


MAXIMUM
MARKS
MARKS
OBTAINED
PERCENTAGE

PHYSICS


CHEMISTRY


BIOLOGY


BOTANY


ZOOLOGY



NURSING THEORY +PRACTICAL


FOUNDATION SCIENCE


TOTAL



17.District Code ( as given in the Prospectus ) :
Native District District in which School / Diploma in
Nursing Studied



18. a. Present Occupation (Please Tick ) : Govt. Service / Private

b. If Service candidate, date of appointment
in Regular Time Scale :



19. Are you applying for Orthopaedically
Physically Disabled Category : Yes / No


Date :
station : Signature of the Candidate
Maximum total marks in the board examination
(all subjects from first year to final year) in
Diploma in Nursing course
Total marks obtained in the board
examination ( all subjects from first year to
final year ) in Diploma in Nursing course

Maximum Marks Marks Obtained



Date Month Year

2






SERVICE PROFORMA : ( To be filled by the forwarding authority )

1 Name of the Candidate


2 Designation


3 Date of entry into Government Service


4 Date of completion of two years of
regular continuous service


5 Total Service as on 31.05.2014


6 Whether selected by Govt. (or) other
Agency ( Specify)

7 Name of the appointing authority


8 Service status
(Put Mark)
Temporary Probationer Approved
Probationer


9 Status of the Institution State Govt. Local Bodies


10 Complete Service particulars till date
( May be furnished in a separate sheet in
the format duly signed by the forwarding
authority)
Sl No Post Place From To


11 Whether the candidate is under any
subsisting contractual obligation, if so
give details.

12 Whether the candidate is working under
the control of :
(Put Mark)
DME DMS DPH OTHERS

13 Station in which the candidate is
presently working and address.



Date :
Office Seal : Signature of the Forwarding Officer with Seal
Office Phone / Fax Numbers

Note: The above particulars should be verified scrupulously and in the event of any
misinformation found later, the forwarding officer will be held responsible.



3


DECLARATION BY THE APPLICANT & PARENT

I (Name in Full & in Block Letters) Son/ Daughter /
Ward of .. an applicant for Post Basic B.Sc (Nursing) course
2014-2015 session hereby solemnly declare that I have not claimed dual nativity in this
regard and I belong to ...(Community) and sub caste ..
I also declare that the information and the statements given in the application, Scrutiny sheet
and enclosures are true, correct & complete. I further declare that if it is found otherwise, I
will be liable to forfeit the seat and / or be removed from the rolls of the institution at
whatever stage of study, I may be, besides making me liable for criminal prosecution.

I .(Name in Full & in Block Letters) Father/
Mother / Guardian of .. an applicant for Post Basic B.Sc
(Nursing) course 2014-2015 session hereby solemnly declare that I am fully aware of the
above declaration & the particulars furnished are correct. I declare that if it is found
otherwise my ward will be liable to forfeit the seat and also be liable for criminal prosecution.



Signature of the Parent/ Guardian Signature of the Candidate








4
1
NAME
2.UseonlyBluecolorBallPointPenfortickingandwriting
4.Writeinsidethewhitebox,whereverwritingisrequired
3 Nameoftheparent/guardian
4 Sex 5
6 Nativity 6a.DetailsofNativity&
Education
7 DateofBirth / / 8 Community 1.OC
9 10 CasteCode
11 Religionwithcode: 12 MotherTongue:
MaximumMarks MarksObtained
13c.
13b.
14a DateofPassingDiplomainNursing / / 14b.
15 NursingCouncilRegistrationNo.
Nurse Midwifery
16 MarksinHSC
17 DistrictCode 18a
/ /
19
Isincerelyaffirmthattheinformationfurnishedabovearetrue
Station
Date SignatureoftheCanidatewrittenthebox
3.Puttickmark()inthecorrectGraycolorboxes.
TotalNo.ofcompletedyearsafter
passingDiplomainNursingason
31.05.2014
Physics Chemistry Biology Botony Zoology
Nursing
Theory+
Practical
Foundation
Science
13a
Maximum
Obtained No.ofattemptsinthe
finalyearDiplomain
NursingExamination
MarksObtainedinthePsychiatry/MidwiferyExamination
DiplomainNursingCourse
NameoftheCaste:
3.MBC
4.SC 4A.SCA 5.ST
MarksobtainedintheBoardExamination(AllSubjects
fromfirstyeartofinalyearinDiplomainNursingcourse)
ADMISSIONTOPOSTBASICB.Sc.(NURSING)20142015SESSION
SCRUTINYFORM
2
1.M 2.F 1.Indian 2.Others
2.BC 2A.BCM
1.TN 2.Others
1 2
Subject
MaximumMarks
MarksObtained
Percentage
Yes No
MobileNo.
PINCODE:
INSTRUCTIONSTOFILLUPSCRUTINYFORM
1.Tobefilledbythecandidatesaspertheentriesmade
intheapplicationformandreturned
AreyouapplyingforOrthopaedically
PhysicallyDisabledcategory
Pasteherefirmly
yourrecent
Photography4cmx
5cmwhichname&
date
Districtinwhich
school/Diplomain
Nursingstudied
NativeDistrict
1.Govt.Service
2.private
18b.Ifservicecandidate
dateofAppointmentin
regulartimeofscaleof
pay
Nationality
ADDRESS
5


T
O

B
E

S
E
N
T

T
O

T
H
E

S
E
C
R
E
T
A
R
Y
,

S
E
L
E
C
T
I
O
N

C
O
M
M
I
T
T
E
E
E

I
N

P
E
R
S
O
N
/

B
Y

R
E
G
D
.

P
O
S
T

/

S
P
E
E
D

P
O
S
T

/

C
O
U
R
I
E
R

S
E
R
V
I
C
E


C
O
M
M
U
N
I
T
Y


(
C
I
R
C
L
E

T
H
E


C
O
R
R
E
C
T

N
U
M
B
E
R
)












A
P
P
L
I
C
A
T
I
O
N

F
O
R

A
D
M
I
S
S
I
O
N

T
O









P
O
S
T

B
A
S
I
C

B
.
S
c
.
,


N
U
R
S
I
N
G

S
P
E
C
I
A
L

C
A
T
E
G
O
R
Y










C
O
U
R
S
E

F
O
R

T
R
A
I
N
E
D

N
U
R
S
E
S

(
M
E
N
T
I
O
N

C
O
D
E


N
O
)












F
O
R

D
I
P
L
O
M
A

I
N

N
U
R
S
I
N
G

C
A
N
D
I
D
A
T
E
S

O
N
L
Y
)
















2
0
1
4
-
2
0
1
5


-

S
E
S
S
I
O
N

F
r
o
m
:


C
a
n
d
i
d
a
t
e

s

m
a
i
l
i
n
g

a
d
d
r
e
s
s
)

.




T
o

.




T
h
e

S
e
c
r
e
t
a
r
y
,

.




S
e
l
e
c
t
i
o
n

C
o
m
m
i
t
t
e
e
,

.







1
6
2
,

P
e
r
i
y
a
r

E
.
V
.
R
.
H
i
g
h

R
o
a
d
,
































K
i
l
p
a
u
k
,

C
h
e
n
n
a
i
-

6
0
0

0
1
0
.


P
I
N

C
O
D
E
:


O
C

B
C

B
C
M
M
B
C
/
D
C

S
C

S
C
A
S
T

1

2

2
A

3

4

4
A

5









T
o

b
e

p
a
s
t
e
d

o
n

o
u
t
e
r

c
o
v
e
r


6