ࡱ> PROq` bjbjqPqP .6:: uttt $$$$ $d1%%%%%'''E1G1G1G1G1G1G1$2h5:k1t''|'''k1%%1g)g)g)'@l%t%E1g)'E1g)g):-H,t/% % X<$'. Y/101.RT5(T5/T5t/D''g)'''''k1k1W)'''1''''$$4"  (Incomplete application will not be entertained) ALL ENTERIES SHOULD BE TYPEWRITING OR WRITTEN IN CAPITAL LETTERS (Incomplete application will not be entertained) ALL ENTERIES SHOULD BE TYPEWRITING OR WRITTEN IN CAPITAL LETTERS   Full Name: Dr./Mr./Mrs./Miss ------------------------------------------------------------ Date of Birth------------------- Present Age-------------- Years------------------ Residential Address (Phone)--------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ 4. Address for Communication ----------------------------------------------------------- ----------------------------------------------------- Phone------------------------------------ Martial Status:------------------------------------------- Mother Tongue----------------------------------------------------------------------------- Caste: S.C./S.T./OBC [attach certificate] Are you enrolled for any program elsewhere? -Yes/No If yes, specify -------------------------------------------------------------------------- (a) Are you employed at present? -Yes/No (b) Position: Supervisor/Executive/Other 11. Have you been sponsored by your employer? -Yes/No 12. For how many years have been employed so far? -Years 13. For how many years have you had administrative /supervisory experience in the field of Disability Rehabilitation. -Years 14. Please give a brief outline of your current official responsibilities: 15. Reasons to join the course: i) ii) 16. Certificate of sponsorship from Employing Organisation This is to certify that Dr./Mr./Mrs./Miss ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ( Candidates designation) ( Department) (organization) Currently employed in our organization of training leading to the Post-Basic Diploma in Orthopaedic & Rehabilitation Nursing Course (Session - 2010 ) for the following reasons. i) ii) 17. (a) we will be paying the fees of the candidate if admitted. (b) We will not pay the fees of the candidate but we have no objection to the candidate joining the course and fulfilling all the course requirements. Name of the head of the department / organization: Address: ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- ----------------------------- ------------------------------ ------------------------------- (Seal of the organization) (Date) (Signature) 18. a)Academic and Professional qualification (Please list your qualification beginning with the latest) Examination PassedName of the InstitutionName of the Board/ University/councilAttendedYear of passing Marks obtained % of marksSubject of studyPercentage of marksClass/DivisionFromTo  b)Work Experience (Please list your work experience beginning with the latest) Name & address employerPlacement of employmentDesignation and nature of workPeriodLast salary drawnReason for leavingFromTo 19. Registration no with name of the Council: 20. Declaration by the Applicant. I here by declare that the information given in this applicant is true, complete and correct to the best of my knowledge and belief. I have carefully read all the rules of the Institute and on admission, agree to abide by them including modifications to the rules, if any, made from time to time. Signature of Applicant Place:- Date:- Documents to be attached (Check List) 1.- DOB/ Birth certificate. 2 .-Copy of the SC/ST/OBC, if applicable. 3.-Certificate of Degree/ Diploma etc. 4.-Experience certificate if any. 5.Registration Certificate of State Nursing Council. 6. 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