Registration Form

Apply Date : 03-Jun-2021
Parental Council Details
Course Applied for Registration : GNM/BSC NursingParental Council States : Madhya Pradesh
Registration No : 33049Registration Date : 26/04/2017
Applicant's Details
Name Mr./Mrs. : INSAF KHANFather Name : VALEE MOHAMMAD
Mother Name. : Date Of Birth : 07/04/1989
Age : 32Birth Place : JALORE
Religion. : Gender : Male
Marital Status : Aadhar No : 585246490462
Email : mannojha39@gmail.comCategory :
Mobile No : 9667933195Secondary Mobile No : 9694512195
Candidate Corresponse Address
Nationality : INDIANRajasthan Domicial :
State : District :
Tehsil :
Current Address : keshar nath colony jalore pin 343001 state rajasthaNPincode :
Permanent Address : keshar nath colony jalore pin 343001 state rajasthan Pincode :
Basic Eduation Qualification Details
SNo. Exam Board Name Passing Year Subject Percentage/Grade/CGPA Roll No
110th
212th
Professional Training Details
Registration Required : Training Centre Name :
Training Centre Address (District, state) : Training Duration (Year) : 3.6
(Training Period) Date From : 01-Jul-2012 To : 31-Jan-2016
Last Degree /Diploma No : Diploma/Last Degree Issue Date :
Training Exam Details
University Name : Passing Year :
Percentage/Grade/CGPA : Roll No (Final Year) :
Upload Required Documents
Secondary Marksheet(Original Scan Copy) : Uploaded
Senior Secondary Marksheet(Original Scan Copy) : Uploaded
Marksheet of GNM/ANM/Bsc Nursing(Original Scan Copy) : Uploaded
Aadhar Card(Original Scan Copy) : Uploaded
Registration Certificate(Original Scan Copy) : Uploaded
Last Degree / Diploma Certificate(Original Scan Copy) : Uploaded
Pay Fees
ReceiptPay DateAmountGST % GST AmountPayPay ModeTransaction IDStatus
3508 03-Jun-2021 2000.00 2000.00 Debit Card 294890306211232784 Successed
Declaration

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 By-Laws made or order and instruction , issue there under so far as they affected me and in the council shall any time after due enquiry order my name removed from Register. i will return to Register the Certificate and badge (if any) issued to me by Council.

INSAF KHAN
APPLICANT'S NAME