VYDEHI INSTITUTE OF NURSING SCIENCES & RESEARCH CENTRE # 82, EPIP Areo, Whitefield, Bongolore - 560 066. Ph : 91.080-284133S'l /2/3/4/5 Fqx : 9l "80-2841 6199 I 2A412956 Affix Photo E.moil : [email protected] Visit us ql www'vims.oc.in Apptn vlNs/GNM,? APPLICATION FORM FOR GENERAL NURSING & MIDWIFERY 6s Name of the Candidate : DD Gender, E E Date of Birth ag. [Tl * Write Date of Birth as l-l_l v*, it is in the SSLC / 10" Standard Marks Cmd Father's Name : Designation: 0ccupation: Annual Ineome : Mother's Name : Occupation: Designation : City : Annual Incorne : Address for Correspotrdencs State Ph : Country : (o) .Pin Code Ph(R): Email : Permanent Address : Ctty State Ph (o) Pin Code Country : : Ph (R): Email : Name of the Local Guardian Address of the Guardian Relationship with guardian City Ph (o) Email ID Mob Native State Mother's Tongue Minority Status : Ph(R) Pincode State f] Retigious f] : Linguistic, if yes, Speciff P.T.O. Educational Qualifi cations : Course / Board Institution Year of Passing Aggregate o/o 10'nstandard l2'ostandard Subjects English Second Language Optional Subjects Attested Photocopies of the Following Certilicates to be erclosed along with 5 recent Passport Size Photographs SSLC / PUC Certilicates and Mark Sheet tr tr Migration Certificate Eligibility Certi{icate tr tr Tfansfer Certificate Conduct Certificate from Head of the Institution last attended tr tr Medicat Fitness Certificate E E' Pass Certification of vaccination Declaration b1'the candidate Port Copy tr tr tr tr tr tr tr tr : I declare that the information provided in this application form is true to the best of my knowledge and belief. Signature of the candidate Date: Place : Signature of the Parent / Guardian