UG Reg No

Photo: (Upload JPG,PNG and GIF Image Only)

Name of Applicant

Expansion of Initial

Date of Birth
Age

 

Sex

Select Male Female Transgender

Mobile

E-mail

Mother Tongue

Blood Group

Nationality

Religion & Community Name

Speciality Applied for

 1.Medical Surgical Nursing
 2.Child Health Nursing
 3.Obstetric & Gynaecological Nursing
 4.Community Health Nursing
 5.Mental Health Nursing

Speciality Option 1

Speciality Option 2

Details of Parents

DETAILS	FATHER	MOTHER
NAME
QUALIFICATION
PERMANENT ADDRESS
PHONE NO
EMAIL ID
ANNUAL INCOME

Name of the Degree

Name of the College & Address

Medium of Instruction

RN No with Date

RM No with Date

University to which college is affiliated

Select The Tamilnadu Dr.MGR Medical University Bits pilani Madras University Others  

Extra Curricular Activities participated Sports / NSS / NCC / Others (Specify):

Year of Experience & Institution Name:

Form Date:

To Date:

Details of Marks Obtained:

	Total Marks	Percentage
1st Year
2nd Year
3rd Year
4th Year
Total

Amount :

₹1550

Marksheet: (Please attach your All 4years marksheet to be upload in PDF format )

    I hereby declare all the above information are true to the best of my Knowledge.

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