4/25/2014 Application Form

http://www.formzero.in/index.php?module=institute&section=courseapplication&event=view&method=view&stageid=330&id=B-Sc-Nursing 1/3

Institute Of Medical Sciences
Banaras Hindu University

APPLICATION FORM FOR B.Sc Nursing 2014

Last date of receipt of duly filled online application: 04.05.2014, till 11:59PM

Candidates are adviced to read the instructions in this link carefully before filling up the registration form

Note : Fields marked with a red asterisk are mandatory for submission of the form. Please keep on clicking the save
button on the top right corner while filling the form to make sure you do not lose any data due to network connectivity
issues. Click on the submit button for finally submitting your data.
First Name
Date of Birth
Category
Application Fee
NEHA
21-11-1995
OBC(non-creamy layer)
1000
Middle Name
Sex

Female
Last Name
Nationality
Only Indian Nationals are allowed
SINGH
India
Person with disability ?
Physically challenged (PC) candidates are not eligible for B.Sc. nursing course
No
Father's Name
RAKESH KUMAR SINGH
Mother's Name
SHARMILA DEVI
Contact information for Correspondence
4/25/2014 Application Form
http://www.formzero.in/index.php?module=institute&section=courseapplication&event=view&method=view&stageid=330&id=B-Sc-Nursing 2/3
House No.
District
Telephone No. with STD/ Mobile
SHIVAPAR(TP NAGAR) NEAR TIWARI
HOTEL
SONEBHADRA
8858242890
Street / Post & Thana
State
Email
POST-PIPARI
UTTAR PRADESH
NEHASHARMILA.95@GMAIL.COM
City
Pin
Mobile Number
RENUKOOT
231217
8858242890
Permanent contact information same as Correspondence ?
I.Sc / 10+2 or equivalent ?
Yes
Appearing
Marks in Intermediate or equivalent examination
Marks obtained in English
Write "NA" if not applicable
Maximum Marks in English
Write "NA" if not applicable
Marks obtained in Biology
Write "NA" if not applicable
Maximum Marks in Biology
Write "NA" if not applicable
Total marks obtained (4 subjects)
Write "NA" if not applicable
NA
NA
NA
NA
NA
Marks obtained in Physics
Write "NA" if not applicable
Maximum Marks in Physics
Write "NA" if not applicable
Marks obtained in Zoology
Write "NA" if not applicable
Maximum Marks in Zoology
Write "NA" if not applicable
Total Maximum marks (4
subjects)
Write "NA" if not applicable
NA
NA
NA
NA
NA
Marks obtained in Chemistry
Write "NA" if not applicable
Maximum Marks in Chemistry
Write "NA" if not applicable
Marks obtained in Botany
Write "NA" if not applicable
Maximum Marks in Botany
Write "NA" if not applicable
NA
NA
NA
NA
DISCLAIMER : Submission of this form alone does not mean that you have successfully applied to the above-
mentioned course. You MUST complete all the stages of the application process (including payment, successful
document upload, etc) to be eligible for selection.
DECLARATION BY THE CANDIDATE
1. I have read the information and instruction booklet carefully.
2. I am an Indian Citizen and have not taken part in any activity subversive to law.
3. The Application Form has been dully filled and signed by me. All the information furnished herein is true and
complete and nothing has been concealed or distorted. If any time it is found that the entries made in my Application
Form are incorrect or any of the information has been concealed or distorted, my admission to B.Sc Nursing course at
the IMS, Banaras Hindu University, shall be liable to be summarily cancelled without any notice whatsoever by the Head
of the Institution.
4. I shall abide by the decision of the Head of the Institution in all matters of admission, discipline, examination,
residence, attendance in the classes and shall abide by the Rules & Regulations of the Banaras Hindu University.
4/25/2014 Application Form
http://www.formzero.in/index.php?module=institute&section=courseapplication&event=view&method=view&stageid=330&id=B-Sc-Nursing 3/3
5. I promise to submit/show original copies of all my Educational Qualification Certificates, Mark Sheets as well as other
relevant Certificates at the time of my admission to the Admission Committee. In the event of failure to do so, my
admission to IMS, BHU shall stand cancelled.
6. I understand that if I fail to submit relevant documents / fulfill the essential criteria for admission, my candidature shall
stand cancelled forthwith even if I have secured success in the merit list of entrance test results.

loading