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P.C.B.SC Form

This document is an application form for admission to the P.B.Sc Nursing Course at KLE Society's Institute of Nursing Sciences in Hubballi. It requires candidates to provide personal details, academic qualifications, and clinical experience, along with a declaration of adherence to the institution's rules. The form also includes a section for parental or guardian consent and outlines the necessary enclosures to be submitted with the application.

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10 views3 pages

P.C.B.SC Form

This document is an application form for admission to the P.B.Sc Nursing Course at KLE Society's Institute of Nursing Sciences in Hubballi. It requires candidates to provide personal details, academic qualifications, and clinical experience, along with a declaration of adherence to the institution's rules. The form also includes a section for parental or guardian consent and outlines the necessary enclosures to be submitted with the application.

Uploaded by

alanwalkerbemai
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PÉ.J¯ï.E.

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«zÁå£ÀUÀgÀ, ºÀħâ½î-580031
KLE SOCIETY’S INSTITUTE OF NURSING SCIENCES
VIDYANAGAR, HUBBALLI – 580031
Off : 0836 -2375506 Mob : 9945076768 (Principal)
Email : klesinshbl@gmail.com Website : www.klesnursing.com

APPLICATION FORM FOR ADMISSION TO


P.B.Sc NURSING COURSE

1. Name of Candidate :…………………………………………………….


2. Permanent Address : ……………………………………………………
…………………………………………………….. Photo
……………………………………………………..
Phone No : ……………………………………………………
Email ID :……………………………………………………..
Aaadhar No. : …………………………………………………….
Blood Group : …………………………………………………….
3. Year of Admission : ……………………………………………………
4. Marks Obtained at
Diploma in Nursing (GNM) a) Total Marks obtained :…………………………………
b) Out of :…………………………………
c) Aggregate Percentage: ………………...........................
To,
The Principal,
KLES Institute of Nursing Sciences,
Vidyanagar, Hubli.

Sir,
I the undersigned wish to seek admission to P.C. B.Sc Nursing Course affiliated to RGUHS,
Bangalore. I am giving below my following particulars and undertaking that if admitted I agree to be
bound by the rules & regulations in force as well as those that may be framed in future by the
institution. I have attached all the original documents and attested copies of all necessary documents
with this admission form. My name has not been registered for any other course in any other
University.

Yours faithfully,

(Signature of the candidate)

DETAILS OF THE CANDIDATE


Full Name of the candidate as entered in
1
previous Marks Card
2 Full Name of Parent/ Guardian

3 Full Postal Address

4 Date of Birth
5 Age
6 Gender
7 Marital Status
8 Nationality
9 Religion/caste
Occupation of father/Guardian &
10
Annual Income
11 Details of Previous education (Diploma
in Nursing (GNM)
 Name of College with address.

 Date of Joining
 Date of Completion
 Duration of Course completed
12 Name & Address of Previous Board
Name of State Nursing Council &
13 Registration Number & Date of
Registration
14. ACADEMIC INFORMATION:
Marks No. of Month & year of
Course Max Marks Percentage
Obtained Attempts Passing

1st year GNM


2nd year GNM
3rd year GNM
Internship
TOTAL

15. CLINICAL EXPERIENCE:


Date of Date of Total years of
Name of the Organization Employed Designation
Joining Relieving experience

16. Name and Address of two Referees:


A) ………………………………………….. B) ……………………………………….
………………………………………… ………………………………………..
………………………………………… ………………………………………..

I declare that the above information is true & correct & documents produced are genuine one.

Place : Signature of the Candidate: ……………………………


Date : Name : ……………………………

Enclosures:
All original document & 4 set attested copies of following documents
1. Marks cards/ course completion certificate of GNM course
2. TC/LC from previous institution
3. Date of Birth Certificate.
4. Migration certificate, if GNM studied outside the Karnataka.
5. State Nursing Council Registration Certificate
6. Experience certificate
7. Recent passport size photographs (2 Nos.)
DECLARATION BY THE CANDIDATE & PARENT/GUARDIAN
1. I am fully aware that my admission to P.C B.Sc Nursing Course is purely provisional and subject to
approval of statutory bodies like INC / RGUHS / KNC / State Government.
2. If admitted I here by agree, to the rules and regulations at present in force or that may be herewith
framed for the governance of the institute and its management and hostels and I undertake that so long
as I am a student of the institute, I do nothing either inside or outside the institute that will interfere
with orderly governance and discipline.
3. I here by agree to make good any loss or damage to books, apparatus, furniture and other belongings
to institute and its attached hostels etc which may be caused by my carelessness, negligence or
wantonness on my part.
4. I hereby solemnly affirm that statements made and information furnished in my application form as
also all the enclosures there to submitted by me are true. Should it however be found that any
information furnished there in is un-true in material particulars, I realize that I am liable for criminal
prosecution and I also agree to forgo my seat in the institute.
5. I hereby assure that I will not indulge or resort myself in any form of anti-social and prohibitory
activities such as ragging or any kind of harassment physical or otherwise. I am fully aware of the
provisions of Indian penal code relating to offences connected with hurt, endangerment of life or
personal safety, wrongful confinement, assault, criminal intimidation and so on, and if I am found
indulging myself in such prohibitory and antisocial activities, I am liable for severe punishment
including removal from the institute and handing over to the police.
6. I hereby declare that I hold myself responsible for the timely payment of dues to the institute during
period of my studies, till the accounts are cleared.
7. I am fully aware that I have to fulfill 80% of attendance requirement to be eligible for University
examinations failing which I myself will be held responsible for the consequences arising out of it.
8. I am aware that fees once paid will not be refunded under any circumstances.
9. I am fully aware that, in-case I want to discontinue before expiry/completion of the course, or wants to
seek transfer to any other college, I shall have to pay full fees (non refundable) then prescribed for all
the remaining years, i.e., for the entire course.
10. I / we hereby declare that I abide by the above-mentioned rules. I / we also declare that I have
carefully gone through the instructions of candidates, hereby mentioned and agree for the same.

Signature of Parent/Guardian Signature of Candidate


Name: Name:
Date: Date:

FOR OFFICE USE ONLY

Mr/Ms: ………………………………………………….is admitted to the P.C. B.Sc Nursing


course for the academic year……………..

Principal
KLES institute of Nursing sciences
Hubli

Approved College Fees: Ist Yr:……………………. IInd yr : …………………………


Paid fees : 1) Rs……………….. . Receipt No:………………. . Dated:………………
2) Rs……………….. . Receipt No:………………. . Dated:………………
3) Rs……………….. . Receipt No:………………. . Dated:………………
4) Rs………………… Receipt No:………………. . Dated:………………

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