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APPLICATION FORM FOR ISSUE OF REGISTRATION CERTIFICATE / TRANSFER OF REGISTRATION TO PNRC

NOTE: WRITE IN BLOCK LETTERS ONLY

FOR OFFICE USE ONLY. PLEASE DO NOT FILL IN THIS SECTION


APPLICATION REF NO.
SYSTEM ID
RN/RM NO.
PERSONAL DETAILS
REGISTRATION FOR: ANM GNM BSC POST BASIC MSC
NAME: PASTE YOUR LATEST
PHOTOGRAPH HERE
FATHER’S NAME: CROSS ATTESTED BY THE
PRINCIPAL
DATE OF BIRTH: DAY: MONTH: YEAR:
MARITAL STATUS: MARRIED UNMARRIED OTHER
RESIDENCE ADDRESS:
MOBILE NO. Applicant signature

EMAIL ID:
ADHAAR NUMBER:
QUALIFICATION DETAILS
BOARD OF
EXAMINATION HELD MAX MARKS MARKS OBTAINED
EXAMINATION
10TH
12TH
QUALIFICATION DETAILS OF NURSING COURSE FOR WHICH APPLYING
ADMISSION IN: MONTH____/YEAR______ EXAMINATION HELD IN: MONTH____/YEAR____
RESULT: MARKS OBT: MAX MARKS: TRAINING COMPLETED IN: MONTH____/YEAR____
FINAL YEAR ROLL NO:
BOARD/UNIVERSITY:
INSTITUTE:
PAYMENT MODE: DEMAND DRAFT DATE: DD NO: BANK:

DATE: APPLICANT SIGNATURE:

1. It is certified that I am personally acquainted with _______________________s/d/w/o __________________. He/She has


passed ________ examination held in _________.
2. He/She bears good moral conduct and character. He/She is applying first time for registration and previously he/she has
never applied for registration in PNRC.
3. It is also certified that above mentioned course of this college is recognized by the INC/BFUHS/PNRC.

Name of Principal: Full Signature of Principal: Stamp of Principal:


DOCUMENTS TO BE ATTACHED
 Application Form
 Affidavit of Candidate Identification Affidavit (Specimen Attached)
 10th DMC copy
 12th DMC copy
 DMC’s of respective course
 Relieving Certificate (New Specimen Attached)
 Aadhaar Card Copy
 Fee in the shape of Demand Draft in favour of “REGISTRAR, PNRC” payable at Mohali or
Chandigarh. The fee is as follows:
Registration Fee:-
MSc. (Nursing) – Rs. 2,000 + Rs. 50 (Form) = Rs. 2,050/-
ANM/GNM/ BSc.(Nursing)/ Post Basic BSc.(Nursing) – Rs. 1,000 + Rs. 50 (Form) = Rs. 1,050/-

NOTE: THE PHOTOCOPIES OF ALL THE DOCUMENTS MUST BE ATTESTED BY


BOTH CANDIDATE AND PRINCIPAL
FORMAT OF RELIEVING CERTIFICATE (TO BE ISSUED BY PRINCIPAL ON INSTITUTE LETTERHEAD)

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