MAHAKOSHAL NURSES REGISTRATION COUNCIL M-78, BLOCK No. 9, HARSHWARDHAN NAGAR, BHOPAL-462003 Prepaid (Form B) Rs. 25 vide R.No.------------------- Form of Application (Rule 9) Attested Dated--------------------(The Central Province Nurses Registration Act, 1936) Photo Application for Admission to Register 1. Name in full (Surname first)-----------------------------Ku./Smt./Shri-------------------------- 2. Single/ Married/Widow/Separated----------------------------------------------------------------- 3. Age---------------Date of Birth------------------------------------------------------------------------ 4. Permanent Address in full---------------------------------------------------------------------------- 5. Present address in full--------------------------------------------------------------------------------- 6. Educational qualification----------------------------------------------------------------------------- 7. Nationality----------------------------------------------------------------------------------------------- 8. Religion--------------------------------------------------------------------------------------------------- 9. Where ---------------------------------------------------------------------------------------------------- 10. Period of Training----------------------------------------to ------------------------------------------- 11. Date Month and Year of Passing Nursing Examination---------------------------------------- 12. Caste--------------------------General/SC/ST/OBC-------------------------------------------------- 13. Name of Examination Council/University from which qualified----------------------------- 14. Registration required as GENERAL NURSES/Sr. MIDWIFE/ /B.Sc.NURSING/G.N.M./ AUXILIARY-NURSE-MIDWIFE. 15. Date of remitting Fee by Bank Draft--------------------------------------------------------------- I enclose original copies of certificates of qualification as detailed below, which may please be returned to me. I also enclose Two recent testimonials by respectable and well known citizens of my town/village including one by a Medical Officer not below the rank of Assistant Surgeon or a private Medical Practitioner holding registrable medical qualifications. I hereby undertake that if I am admitted to register, I will , in the practice of my profession as a observe and be bound by the provision of the Act and the rules and byelaws made or order and instructions, issued there under so far as they affect me and if the Council shall at any time after due enquiry order my name to be removed from the register. I will return to Registrar the certificate and badge (If any) issued to me by the council. Date--------------------------------------------------------------- Place-------------------- Signature of Applicant Note- 1. The form must be forwarded by the Head of the Training Centre after verification of the Training period under his/her Signature & Seal (As per proforma given at the reverse) The Period of Training must be complete in each case otherwise form will be cancelled. 2. Each application form must be accompanied by Three pass-port size photographs of the applicant duly attested by a Gazetted officer. The photo should not be pasted on the form. 3. The amount of the fee sent directly by CROSSED BANK DRAFT PAYABLE TO REGISTRAR MAHAKOSHAL NURSES REGISTRATION COUNCIL BHOPAL. Please strike out what is not applicable 4. A fine of Rs. 100.00 will be charged if form is presented after one month of declaration of result of examination. (1) Annexure:- (a) Diploma in General Nursing----------------------------------------------------------------- (b) Qualification Certificate of midwifery----------------------------------------------------- (c) Qualification Certificate of Auxiliary Nurse-Midwife---------------------------------- (d) Qualification Certificate of Health Visitor------------------------------------------------ (e) Qualification Certificate of Trained Dai-------------------------------------------------- (2) Original copies of testimonials---------------------------------------------------------------------------- Name, address and designations of testifying persons and date of issue of testimonial (1)-------------------------------------------------------(2)----------------------------------------------------- (3) Particulars regarding registration with the Mahakoshal Nurses Registration Council Bhopal or with any other Council. Name of Nurses Number & Council where Date of Category in which registered such as previously registered Registration Nurse Midwife Health visitor Dai Auxiliary Nurses-Midwife Other Signature of Applicant Certified that the period of training of Ku./Smt./Shri-------------------------------------------------------------------------B.Sc. Nursing 4 years/General Nurses 3 Years/Sr. Midwife 6 months/ A.N.M. 2 Years/Female Health worker/Promotee LHV/P.H. Nursing/Nursing education(Sister tutor) is from--------------------------------------------------to------------------------------------------------------ Signature and Seal of To, Head of Training Centre The Registrar, Mahakoshal Nurses Registration Council Bhopal (M.P.) RATE OF FEE FOR REGISTRATION Course Registration Fee 1. B.Sc. Nursing Rs. 1000/- 2. G.N.(New Course) Rs. 1000/- 3. General Nurse Rs. 500/- 4. Midwife Rs. 500/- 5. A.N.M./Female Health Worker/H.Visitor Rs. 600/- 6. Promotee L.H.V. Rs. 300/-
