Version: 1.

14, Date: 01 Aug 2018

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Directorate General of Nursing & Midwifery

Data Collection Tool Photo

Place of posting:_______________________________________ District:____________________

General Information

BNC Midwifery Registration No.: National ID No.:

Personal Information

Full Name (English) Name (Bangla)

(Capital Letter)

Sex (Tick) Male Female Passport Number

Father’s Name Mother’s Name

Date of Birth Birth Place (District)

(Day) (Month) (Year)

Marital Status (Tick) S M W D Se

Religion (Tick) I Hi Bu Ch O
S=Single, M=Married, W=Widow, D=Divorced, Se=Separated
I=Islam, Hi=Hindu, Bu=Buddhist, Ch=Christian, O=Others

Mobile Number
E-mail Address

Official Information

BPSC Merit No./Sl No BPSC registration No:

Specialty posting:

e.g.: ICU/ CCU/ Cardiovascular/ Child/ Psychiatric nursing ect.

Mailing Addresses
Present Permanent

Village/House/Road

Division

District

Thana/Upazilla

Post Office

Postal Code

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 General Educational Qualification
Level of Education (Please tick your desired
option) Board Division/CGPA Year Country
1 2 3 4 5

SSC/ O Level/ Dakhil/ Equivalent

HSC/ A Level/ Alim/ Equivalent

Professional Educational Qualification

Level of Education Institute/College/University Division/Class/CGPA Year Country
Diploma in Midwifery

If others, specify:__________________

BNMC Registration Information

Last Renewal
First Issue Date
Type of Registration (Please tick your desired option) Reg. Number Date
dd/mm/yyyy
dd/mm/yyyy
Diploma in Midwifery / / / /

Specialty
/ / / /
(Specify):_____________________________
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Service Particulars

Date of Appointment G.O. No. of

Appointment
(Day) (Month) (Year)
G.O. No. of
Date of Joining Joining

(Day) (Month) (Year)

Designation Workplace Name of workplace &

Pay Scale Basic Pay
Category** District Name
1 2 3 4 5

Midwife

**Workplace MCH=Medical College Hospital, MI=Medical Institute, H=Hospital & District Hospital, DC= Dental College, DDHO=
Category Divisional Director Health Office, CSO=Civil Surgeon Office, CDC=Chest Diseases Clinic, NI=Nursing Institute,
NC=Nursing College, MFPC= Model Family Planning Clinic, UHC=Upazilla Health Complex, RHC= Rural Health Complex,
USC=Union Sub Center

Signature of Employee Date: 30 August 2018

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