Form No: …………......................
APPLICATION FORM : 20____ - 20____
Course applying for Admission ( Tick )
B.Sc. (Nursing) GNM (Nursing)
Candidate Roll No. of
(WBJEEB/JENPAS)
WBJEEB/JENPAS RANK
If not appeared in any of the entrance examination (PLEASE TICK in the bracket)
Name of the Candidate:
Date of Birth:
Date Month Year
Religion:
Marital Status: Single Married Others _____________
Aadhar No:
Category: ST SC General Others _____________
Student
Phone No:
Email ID:
Father's Name
Mothers's Name
Permanent Address:
Pin Code: State:
Phone No. :
Address for Correspondence:
Pin Code: State:
Phone No. :
Fathers'
Mobile No.
Guardian/Husband
Mobile No.
Guardian/Husband Name (If
Married mention your
husband name)
Name of Local Guardian
Relationship with candidate
Blood Group
Local Guardian Address with Contact No.
Academic Qualification:
Total Marks Percentage
Total
Name & Address of Name of the Roll no in Registration Year of Obtained in in
Marks
school Board / Council admit card No. Passing Compulsory Compulsory
Obtained
subjects subjects
Others
Medium:-
English Hindi (Specify)…………………………………….
Documents Required Xerox (Self Attested):
o 2 copies of Mark sheet & Pass Certificate of Madhyamik (Class X).
o 2 copies of Mark sheet & Pass Certificate of Higher secondary (Class XII).
o 2 copies of Madhyamik (Class X) Admit Card.
o 2 copies of School Leaving/Migration Certificate with original copy to be submitted
o 2 copies of Residential Certificate of West Bengal Issued by Gram
Panchayat/M.L.A/S.D.O/B.D.O with original copy to be submitted
o 2 copies of attested ST/ SC/ General/ Other Category Certificate.
o 4 Copies of Passport size color photo.
o 2 copies of attested Aadhar Card.
o Medical Fitness Certificate with Blood Group.
o 2 copies of attested Father Aadhar Card
o 2 copies of attested Mother Aadhar Card
o 2 Copies of Father Passport size color photo.
o 2 Copies of Mother Passport size color photo.
o 2 Guardian/ Husband Passport size color photo.
DECLARATION BY THE CANDIDATE:
I have read all the rules and regulation mentioned in the prospectus and shall abide by them. I
hereby declare that the information is true and correct to the best of my knowledge and behalf.
Date:________________
_________________________________
Place:________________ Signature of the Candidate
DECLARATION BY THE PARENTS
I hereby declare that I have known the financial obligation and I can afford to pay all the cost
and I undertake to pay the tuition and other fees payable to the nursing school under the rules
in force & which may be framed from time to time by the Management. I am aware that the fee
paid to the nursing school for admission will be forfeited in case of her discontinuation of the
studies for any reason.
I also stand responsible for the good conduct and good behavior of my ward and I shall ensure
that she attends all the classes, tests and viva conducted from time to time during the period of
her studies in the nursing school. I understand, a student may be asked to leave the nursing
school at any time of her misbehavior and irregular attendance. In such a case, I am aware that
the fee paid by me is not refundable, transferable or adjustable.
I also stand by the declaration given by my daughter to the nursing school
Date:________________
_________________________________
Place:________________ Signature of the Parents
