2

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Øa- Name of Program Study Centres IGNOU CENTRE Address of Admission Centre

1 Government Nursing College, Ujjain IGNOU, Bhopal Health and Wellness Centres (HWC) Cell Third Floor, Annexe Building National Health Mission Jail Road, Arera Hills, Madhya Pradesh

Tel: - 0755-4020145

2 GNMTC, Raisen IGNOU, Bhopal

3 GNMTC, Datia IGNOU, Bhopal

4 GNMTC, Dewas IGNOU, Bhopal

5 GNMTC, Jhabua IGNOU, Bhopal

6 GNMTC, Mandsaur IGNOU, Bhopal

7 GNMTC, Vidisha IGNOU, Bhopal

8 GNMTC, Rajgarh IGNOU, Bhopal

9 District Hospital, Dhar IGNOU, Bhopal

10 District Hospital, Ratlam IGNOU, Bhopal

11 District Hospital, Bhind IGNOU, Bhopal

12 District Hospital, Shivpuri IGNOU, Bhopal

13 District Hospital, Bhopal (J P Hospital) IGNOU, Bhopal

14 RHFWTC, Indore IGNOU, Bhopal

15 RHFWTC, Gwalior IGNOU, Bhopal

16 SIHMC, Gwalior IGNOU, Bhopal

17 College of Nursing, Indore (DME) IGNOU, Bhopal

18 College of Nursing, Bhopal (DME) IGNOU, Bhopal

19 College of Nursing, Gwalior (DME) IGNOU, Bhopal

20 Chirayu College of Nursing, Bhopal IGNOU, Bhopal

21 Kushabhau Thakre College of Nursing, Bhopal

IGNOU, Bhopal

22 Peoples' College of Nursing, Bhopal IGNOU, Bhopal

23 LN College of Nursing, Bhopal IGNOU, Bhopal

24 Choithram College of Nursing, Indore IGNOU, Bhopal

25 Pragyan College of Nursing, Bhopal IGNOU, Bhopal

26 Government Rani Durgawati Nursing College, Jabalpur

IGNOU, Jabalpur Government Rani Durgawati Nursing College Near High Court, Elgin Hospital Campus, Civil Lines, Jabalpur (MP)

27 GNMTC, Seoni IGNOU, Jabalpur

28 District Hospital, Sagar IGNOU, Jabalpur

29 District Hospital, Shahdol IGNOU, Jabalpur

30 RHFWTC, Jabalpur IGNOU, Jabalpur

31 College of Nursing, Rewa (DME) IGNOU, Jabalpur

32 College of Nursing, Jabalpur (DME) IGNOU, Jabalpur

33 Jabalpur Institute of Health Science, Jabalpur

IGNOU, Jabalpur

3

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lR;kfir Nk;kizfr;ka lkFk esa ykuk vfuok;Z gS %&

1- ch-,l-lh- uflZax] iksLV csfld ch-,l-lh-] th-,u-,e- ,oa ch-,-,e-,l- mRrh.kZ vadlwphA

2- 10oha dh mRrh.kZ vadlwphA

3- jftLVªkj ulsZl dkmafly@ e/;izns’k vk;qosZn] ;qukuh fpfdRlk iz.kkyh ,oa izkd`frd fpfdRlk

cksMZ dk oS/k iath;u izek.k i=A

4- uohu ikliksVZ lkbZt dk lR;kfir QksVksaA

5- :i;s 500@& ds LVkEi isij ij jkf’k :i;s nks yk[k dk ca/k i= ftlesa izos’k i'pkr 6 ekg

dk izf’k{k.k iw.kZ djus ,oa gsYFk ,oa osyusl lsaVj ij inLFkkiuk mijkar fujarj U;wure rhu

o"kZ dk;Z laiknu dh lgefr dk mYys[k gksA

6- vuqfoHkkxh; vf/kdkjh ¼jktLo½] e/; izns’k }kjk tkjh tkfr izek.k&i=A

7- ewy fuoklh izek.k&i=A

8- esMhdy fQVusl izek.k i=A U;wure ,e-ch-ch-,l fpfdRld }kjk] izf’k{k.k esa izos’k ls iwoZ 15

fnol ds Hkhrj tkjh fd;k gqvkA

9- lafonk vk/kkj ij dk;Zjr LVkWQ ulZ dh fu;qfDr dk izFke fnukad ,oa ca/k&i= (Bond)

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10- vuqHko izek.k i=A

11- lfVZfQdsV dkslZ bu dE;wfuVh gsYFk p;u ijh{kk dh vadlwph ,oa izos’k i= ewyr% ,oa lR;kfir

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tkosxkA bl laca/k esa dksbZ vH;kosnu ekU; ugha gksxkA

4

NORMALIZATION FORMULA

Normalization mark of Jth candidate in the ithsession M̂ij

Here,

Mij : actual marks secured by the jthcandidate in the ith sessions

M̅gt : average marks of the top 0.1% of the candidates considering all sessions

Mgq : sum of mean and standard deviation marks of the candidates in the paper

considering all sessions

M̅ti : average marks of the top 0.1% of the candidates in the ithsessions

Miq : sum of the mean marks and standard deviation of the ithsession

Once the answers are checked and assessed, the normalized marks of a candidate will be calculated corresponding to the actual marks secured by the candidate in the examination and the Score card will be devised based on the normalized marks.

5

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Øa- Name of Program Study Centres Name of IGNOU Regional Centre

1 Government Nursing College, Ujjain IGNOU, Bhopal

2 GNMTC, Raisen IGNOU, Bhopal

3 GNMTC, Datia IGNOU, Bhopal

4 GNMTC, Dewas IGNOU, Bhopal

5 GNMTC, Jhabua IGNOU, Bhopal

6 GNMTC, Mandsaur IGNOU, Bhopal

7 GNMTC, Vidisha IGNOU, Bhopal

8 GNMTC, Rajgarh IGNOU, Bhopal

9 District Hospital, Dhar IGNOU, Bhopal

10 District Hospital, Ratlam IGNOU, Bhopal

11 District Hospital, Bhind IGNOU, Bhopal

12 District Hospital, Shivpuri IGNOU, Bhopal

13 District Hospital, Bhopal (J P Hospital) IGNOU, Bhopal

14 RHFWTC, Indore IGNOU, Bhopal

15 RHFWTC, Gwalior IGNOU, Bhopal

16 SIHMC, Gwalior IGNOU, Bhopal

17 College of Nursing, Indore (DME) IGNOU, Bhopal

18 College of Nursing, Bhopal (DME) IGNOU, Bhopal

19 College of Nursing, Gwalior (DME) IGNOU, Bhopal

20 Chirayu College of Nursing, Bhopal IGNOU, Bhopal

21 Kushabhau Thakre College of Nursing, Bhopal IGNOU, Bhopal

22 Peoples' College of Nursing, Bhopal IGNOU, Bhopal

23 LN College of Nursing, Bhopal IGNOU, Bhopal

24 Choithram College of Nursing, Indore IGNOU, Bhopal

25 Pragyan College of Nursing, Bhopal IGNOU, Bhopal

26 Government Rani Durgawati Nursing College, Jabalpur IGNOU, Jabalpur

27 GNMTC, Seoni IGNOU, Jabalpur

28 District Hospital, Sagar IGNOU, Jabalpur

29 District Hospital, Shahdol IGNOU, Jabalpur

30 RHFWTC, Jabalpur IGNOU, Jabalpur

31 College of Nursing, Rewa (DME) IGNOU, Jabalpur

32 College of Nursing, Jabalpur (DME) IGNOU, Jabalpur

33 Jabalpur Institute of Health Science, Jabalpur IGNOU, Jabalpur

6

p;fur vH;kfFkZ;ksa dh lwph

SN ROLLNO RANK NAME ALLOTED PSC NAME ALLOTED

CATEGORY

1 190608902 788 PREETIBALA PATIDAR College of Nursing, Indore (DME) UR/X/OP

2 190608488 807 RAMA YADAV SIHMC, Gwalior UR/X/OP

3 190605702 1093 JAGRITI TIWARI SIHMC, Gwalior UR/X/OP

4 190604178 1367 NITU SHARMA District Hospital, Ratlam UR/X/OP

5 190607827 385 AMBIKA HARINKHEDE College of Nursing, Bhopal (DME) OBC/X/OP

6 190606685 822 MANISHA Peoples' College of Nursing, Bhopal OBC/X/OP

7 190602014 1904 NASLEEM BABY RHFWTC, Jabalpur OBC/X/OP

8 CHO20023594 348 SURENDRA KUMAR Govt College of Nursing, Ujjain UR/X/OP

9 CHO20049760 349 NARPAT SINGH District Hospital, Ratlam UR/X/OP

10 CHO20024458 350 KISHAN SHARMA District Hospital, Ratlam UR/X/OP

11 CHO20007651 351 SWATI SONI RHFWTC, Jabalpur UR/X/OP

12 CHO20009277 352 PANKAJ KUMAR RHFWTC, Gwalior UR/X/OP

13 CHO20014275 353 AMIT KUMAR College of Nursing, Gwalior (DME) UR/X/OP

14 CHO20017379 354 SHANKAR LAL SAINI College of Nursing, Gwalior (DME) UR/X/OP

15 CHO20002247 355 MAHAVEER NAGAR LN College of Nursing, Bhopal UR/X/OP

16 CHO20010082 356 BIBHUSUNDAR NAYAK District Hospital, Bhind UR/X/OP

17 CHO20033070 357 AJAY SHARMA LN College of Nursing, Bhopal UR/X/OP

18 CHO20001886 358 HEMANT BAIRWA GNMTC, Raisen UR/X/OP

19 CHO20037375 359 SUBHASH CHANDRA Kushabhau Thakre College of Nursing, Bhopal

UR/X/OP

20 CHO20041193 360 KARTAVYA THAKER GNMTC, Jhabua UR/X/OP

21 CHO20013444 361 BODU RAM MEGHWAL LN College of Nursing, Bhopal UR/X/OP

22 CHO20008878 362 NIKITA SINGH GNMTC, Datia UR/X/OP

23 CHO20029833 364 AMIT MANDAL GNMTC,Vidisha UR/X/OP

24 CHO20045728 365 SUKHDEV SINGH District Hospital, Bhind UR/X/OP

25 CHO20007088 366 SUNIL KUMAR NAGAR GNMTC, Rajgarh UR/X/OP

26 CHO20014873 367 SUBHASH KUMAR KHYALIA District Hospital, Bhind UR/X/OP

27 CHO20010102 368 RAHUL KUMAR SINGHAL GNMTC,Vidisha UR/X/OP

28 CHO20016736 370 KAPIL MEVAFAROSH College of Nursing, Bhopal (DME) SC/X/OP

29 CHO20054057 371 KRISHAN AVTAR KUMAWAT

GNMTC, Seoni UR/X/OP

30 CHO20040802 372 DINESH KUMAR GNMTC,Vidisha UR/X/OP

31 CHO20028814 373 KANA RAM PARIHAR GNMTC,Vidisha UR/X/OP

32 CHO20018280 374 RAJESH GNMTC,Vidisha UR/X/OP

33 CHO20024867 375 GULAB CHAND NAGAR District Hospital, Shahdol UR/X/OP

34 CHO20010004 376 RAMESH KUMAR District Hospital, Shahdol UR/X/OP

35 CHO20036824 377 VIKRAM SINGH DHERAWAT District Hospital, Shahdol UR/X/OP

36 CHO20003231 1825 ASHOK KUMAR MALVIYA College of Nursing, Bhopal (DME) SC/X/OP

37 CHO20041501 1984 VIVEK KUMAR SAHU College of Nursing, Jabalpur (DME) OBC/X/OP

38 CHO20009882 2284 MOHSIN ALI SHAH GNMTC, Dewas UR/X/OP

39 CHO20024426 2331 KAVITA CHOUDHARY GNMTC, Dewas OBC/X/OP

40 CHO20023300 2577 VIBHA NAGLE Chirayu College of Nursing, Bhopal UR/X/OP

41 CHO20016763 3207 ABHA KHARE Chirayu College of Nursing, Bhopal UR/X/OP

42 CHO20007800 3213 NIKITA GUPTA Chirayu College of Nursing, Bhopal EWS/X/OP

43 CHO20022799 3345 SACHIN PATEL District Hospital, Dhar OBC/X/OP

7

44 CHO20026557 3368 SWATI SHARMA LN College of Nursing, Bhopal OBC/X/OP

45 CHO20028196 3371 MOHD AYYUB AKHTAR Jabalpur Institute of Health Science, Jabalpur

OBC/X/OP

46 CHO20011476 3385 RAGINI PATEL College of Nursing, Jabalpur (DME) OBC/X/OP

47 CHO20023174 3392 BHARAT LAL USRETHE GNMTC,Vidisha OBC/X/OP

48 CHO20015706 3405 SANGEETA DHAKAD Kushabhau Thakre College of Nursing, Bhopal

OBC/X/OP

49 CHO20025434 3411 RAM KISHOR PATEL LN College of Nursing, Bhopal OBC/X/OP

50 CHO20037119 3420 ARTI SEN College of Nursing, Gwalior (DME) OBC/X/OP

51 CHO20034355 3422 JYOTI KHEMRAJ TURKAR Kushabhau Thakre College of Nursing, Bhopal

OBC/X/OP

52 CHO20015423 3427 KAJAL RAJPUT District Hospital, Shivpuri OBC/X/OP

53 CHO20005706 3435 RANI RATHORE GNMTC, Datia OBC/X/OP

54 CHO20022126 3446 POOJA PATIDAR Peoples' College of Nursing, Bhopal OBC/X/OP

55 CHO20037922 3450 RADHIKA LAKHERA Chirayu College of Nursing, Bhopal OBC/X/OP

56 CHO20000551 3457 SUNITA DHAKAD Kushabhau Thakre College of Nursing, Bhopal

OBC/X/OP

57 CHO20030343 3458 SHEELA RAJ SAHU GNMTC, Raisen OBC/X/OP

58 CHO20028260 3460 GAYTRI THAKRE Kushabhau Thakre College of Nursing, Bhopal

OBC/X/OP

59 CHO20030359 3467 POOJA PATEL District Hospital, Shahdol OBC/X/OP

60 CHO20052152 3481 PRIYANKA GNMTC,Vidisha OBC/X/OP

61 CHO20024796 3488 DEVENDRA SINGH DHAKAD District Hospital, Shahdol OBC/X/OP

62 CHO20047136 3494 DEEPAK KUMAR RAJAK GNMTC, Jhabua OBC/X/OP

63 CHO20050421 3499 MONIKA WANKHEDE District Hospital, Shahdol OBC/X/OP

64 CHO20008852 3519 DHIRENDRA KUMAR PATEL GNMTC, Jhabua OBC/X/OP

65 CHO20044516 4657 ARVIND KUMAR MARAWI J P Hopsital, Bhopal ST/X/OP

66 CHO20047306 4967 AMIT UTRADHI GNMTC, Dewas UR/H/OP

67 CHO20003070 5297 SARASTI JAIN District Hospital, Sagar EWS/X/OP

68 CHO20028718 6526 AAKRITI MISHRA Choithram College of Nursing, Indore EWS/X/OP

69 CHO20027511 6818 NIDHI BILLOREY Govt Rani Durgawati College of Nursing, Jabalpur

EWS/X/OP

70 CHO20020502 7550 VIBHA NIRGUDE Chirayu College of Nursing, Bhopal SC/X/OP

71 CHO20045838 7554 PUSHPA RANGARE RHFWTC, Jabalpur SC/X/OP

72 CHO20000661 7568 SANTOSH THAKUR Choithram College of Nursing, Indore EWS/X/OP

73 CHO20023608 7596 KIRAN GORAV Pragyan College of Nursing , Bhopal SC/X/OP

74 CHO20025503 7603 PREETI AHIRWAR Kushabhau Thakre College of Nursing, Bhopal

SC/X/OP

75 CHO20023891 7604 ARTI NAGWANSHI LN College of Nursing, Bhopal SC/X/OP

76 CHO20007616 7661 SHYAM SUNDAR District Hospital, Shivpuri SC/X/OP

77 CHO20018596 7673 NIKESH KANADE Chirayu College of Nursing, Bhopal SC/X/OP

78 CHO20030975 7681 PREETI NIGAM Kushabhau Thakre College of Nursing, Bhopal

SC/X/OP

79 CHO20025251 7685 SHWETA LAVAHE GNMTC, Raisen SC/X/OP

80 CHO20041759 7689 CHANDRAKANT GARG SIHMC, Gwalior SC/X/OP

81 CHO20000127 7700 KRISHNADEV SONKAR College of Nursing, Rewa (DME) SC/X/OP

82 CHO20005169 7733 RANJANA JATAV GNMTC, Dewas SC/X/OP

83 CHO20024309 7741 SHIKHA PANDOLE District Hospital, Shahdol SC/X/OP

84 CHO20025677 7743 GAUTAMEE YADAV District Hospital, Dhar SC/X/OP

85 CHO20006784 7748 VISHAKHA DONGERE District Hospital, Ratlam SC/X/OP

8

86 CHO20021712 7761 NEHA AHIRWAR District Hospital, Shahdol SC/X/OP

87 CHO20013344 7776 ASHOK KUMAR CHAUDHARY

GNMTC, Rajgarh SC/X/OP

88 CHO20054682 7778 UPDESH RAJORIYA District Hospital, Dhar SC/X/OP

89 CHO20054900 8248 BHAWANA JAIN College of Nursing, Bhopal (DME) EWS/X/OP

90 CHO20053521 9740 POONAM SHARMA College of Nursing, Bhopal (DME) EWS/X/OP

91 CHO20032546 10424 KIRTI TRIPATHI Choithram College of Nursing, Indore EWS/X/OP

92 CHO20030049 11081 BADAN SINGH NARWARIYA SIHMC, Gwalior OBC/H/OP

93 CHO20046014 12222 MANSI KHANDELWAL College of Nursing, Rewa (DME) EWS/X/OP

94 CHO20019132 15302 GEETA PANIKA Govt Rani Durgawati College of Nursing, Jabalpur

ST/X/OP

95 CHO20011161 15707 KALPANA KUMARE LN College of Nursing, Bhopal ST/X/OP

96 CHO20041930 15709 SUNITA KAWASE District Hospital, Dhar ST/X/OP

97 CHO20027693 15714 SARITA MARSKOLE Govt Rani Durgawati College of Nursing, Jabalpur

ST/X/OP

98 CHO20007766 15725 SHILPI MAURYA SIHMC, Gwalior ST/X/OP

99 CHO20027607 15734 RAJA Govt College of Nursing, Ujjain ST/X/OP

100 CHO20025297 15738 SARITA SOLANKI College of Nursing, Indore (DME) ST/X/OP

101 CHO20022985 15743 ANKITA DHURWEY Peoples' College of Nursing, Bhopal ST/X/OP

102 CHO20010318 15776 ANJELA DILRAJ College of Nursing, Indore (DME) ST/X/OP

103 CHO20008489 15784 PRABHU MACHAR GNMTC, Jhabua ST/X/OP

104 CHO20013065 15786 NIRMLA ASALIYA Chirayu College of Nursing, Bhopal ST/X/OP

105 CHO20036398 15815 MONIKA SINGH Chirayu College of Nursing, Bhopal ST/X/OP

106 CHO20029245 15825 LAL SINGH AWAYA Choithram College of Nursing, Indore ST/X/OP

107 CHO20040505 15858 NIRMALA KOL Govt College of Nursing, Ujjain ST/X/OP

108 CHO20013247 15870 RELAM TOMAR GNMTC,Vidisha ST/X/OP

109 CHO20024735 15875 KIRAN MOHNIYA GNMTC,Vidisha ST/X/OP

110 CHO20012320 15884 LAXMI SOLANKI District Hospital, Sagar ST/X/OP

111 CHO20005956 15892 KAVITA RATHORE GNMTC, Datia ST/X/OP

112 CHO20029124 15910 RAJENDRA District Hospital, Shivpuri ST/X/OP

113 CHO20013022 15916 TAPASYA KATARA District Hospital, Shivpuri ST/X/OP

114 CHO20013731 17456 GYANENDRA PRASAD TIWARI

District Hospital, Bhind EWS/X/OP

(On non-Judicial Stamp Paper of Rs. 500/-) National Health Mission

SURETY BOND

THIS DEED OF BOND IS MADE ON…………….DAY OF………………….2019

KNOW ALL MEN BY THESE PRESENT THAT WE,

Mr./Miss………………………………………………… S/D/W/O Mr./Mrs. ________________

Residing at __________ (hereinafter called the “candidate”) and (2)

Mr./Mrs./Miss___________ S/D/W/O Mr./Mrs. ___________residing at

___________ (hereinafter called the “surety”) do hereby by bound ourselves and

our respective heir’s executors and administrators, to the Mission Director,

National Health Mission (hereinafter called the “NHM”) on demand Rs. ________/-

in respect of the candidate’s Certificate Course in Community Health (hereinafter

called the “Programme”).

Signed and delivered this _________________ Day of _______________

Signature___________ Signature ___________

(Candidate) (Surety)

WHEREAS on his/her request, the competent Authority at state Health

Department/State Health Society has selected the candidate for the programme

conducted by the IGNOU commencing from the__________ date of ________ 2019

and offered the candidate with sponsorship for undergoing the same vide letter of

offer dated.…/…./20……….

Now the condition of above written bond is that the candidate (1) Shall

successfully complete the programme, and (2) shall sever State Health

Department/State Health Society, Madhya Pradesh thereafter for a minimum

period of three (03) years after successful completion of the programme

(hereinafter referred to as the “Bond period”). Whereas for a minimum period of

three (03) years, then the above written bond shall lapse otherwise it shall be and

remain in full force valid.

That further or in the alternative another condition of the above bond is that if the

candidate commits any breach of his/her undertakings for whatsoever reasons or

in case he/she fails to complete the programme successfully and/or serve the State

Health Department/State Health Society, Madhya Pradesh for the stipulated bond

period thereafter he/she and his/her surety shall jointly and severally compensate

the State Health Department/State Health Society, IGNOU fee (Covers study

materials and counseling fee) boarding and lodging transport expenses etc. paid

during the programme and this expenses incurred by it on account of and in

connection with the programme and this amount will recovered from him/her and

/or from his/her surety. However the total amount recoverable under this clause

shall not exceed Rs. _________/- (Rupees _________________only).

Signed jointly and severally by each of us on this _________day of

_______(month), _______(Year) in the presence of the following witnesses:

1. Candidate Signature ___________

Candidate Name ______________ Address _____________________

2. Signature ____________________ Signature ___________ Name: ______________________ (Surety) Address _____________________

Attested by Notary Public

99

INDIRA GANDHI NATIONAL OPEN UNIVERSITYMAIDAN GARHI, NEW DELHI-110 068

APPLICATION FORM(To be submitted to School of Healh Sciences along with the consolidated details of data of each selected student in Hard and Soft copy by MOHFW)

APPLICATION NO.

Enrolment No. (For Office Use)

INSTRUCTIONS1. Please read the instructions before filling up the form (Appendix 26).2. Please use Black/Blue Ball Point Pen in boxes using English CAPITAL LETTERS or English numerals.3. Write in CAPITAL LETTERS only within box. Leave blank between words as shown in the example below.4. Attach relevant certificates with application form.5. Attach DD in favour of IGNOU payable at Delhi (to be paid by MOHFW).

A B C D E F G I J K L N O P Q R S T U V X Y Z 0 1 2 3 4 5 6 7 8 9

Signature of Applicant

PHOTOGRAPH

Affix your latestpassport sizephotograph(4 cm x 5 cm)duly attested

by you4. Regional Centre Code:

1. Name of the Programme Applied:

5. Programme Study Centre Code:

7. a. Are your registered with (Ignou)(Please write relevantcode in the box) A1 -

YesB2 - No

If yes, Programme Code:

Enrolment No. :

8. Name of the Candidate:(as in class X/XII mark sheetor equivalent certificiate)

9. Father/Mother/Husband /oName :(Please write S/o or D/o forFather/Mother’s Name andW/o for Husband’s Name)

10. Address for Correspondence : (Please do not give POST-BOX Number. Use Capital Letters and give space between words)

a) House No. : b) Street Name :

c) Locality/Mohalla:

d) Tehsil/District:

e) City : f) Pin Code:

g) State:

11. Contact Details: a) Landline No. Fax, if any: STD No. Phone Number FAX Number

b) e-mail ID: c) Mobile No.:

Date Month Year12. Date of Birth: 13. Nationality A1 - IndianB2 - Others,pl. specify

14. Gender(Pls. write relevantcode in the box)

A1 - MaleB2 - FemaleC3 - Other

15. Category(Pls. write relevantcode in the box)

A1 - GeneralB2 - SCC3 - STD4A - OBC (Creamy)D4B OBC (Non Creamy)

16. Area(Pls. write relevantcode in the box)

A1 - UrbanB2 - RuralC3 - Tribal

17. Marital Status(Pls. write relevantcode in the box)

A1 - SingleB2 - Married

18. Religion(Pls. write relevantcode in the box)

A1 - HinduB2 - MuslimC3 Christian

G7 ParsiH8 JewsI9 Others

D4 SikhE5 JainF6 Buddhist

2. Programme Code:

6. State Code:

A1 EnglishB2 HindiC3 Others

3. Medium of Study(Write code in the box)

20. Social Status(Pls. write relevantcode in the box)

A1 - Ex-ServicemanB2 - War WidowsC3 - Not Applicable

21. Whether Kashmiri Migrant(Pls. write relevantcode in the box)

A1 - YesB2 - No

22. Employment Status (Pls. write relevantcode in the box)A1 - UnemployedB2 - IGNOU regular employeeC3 - EmployedD4 - KVS employee

19. Whether Minority(Pls. write relevantcode in the box)

A1 - YesB2 - No

100

23. Details of Scholarship being received, if anya) Annual Scholarship Amount c) Fimily Income (annual) d) Below Poverty Line

A1 Yese) Jain Inmates

A1 Yes

24. a) Whether a Person with Disability(Pls. write relevantcode in the box)

b) If yes, kindly provide details of disability:(Pls. write relevantcode in the box)

A1 - Speech and Hearing ImpairmentB2 - Locomotor ImpairmentC3 - VVisual ImpairmentD4 - Low Vision

b) Deptt. offering Scholarship:A1 Government

Mental Illness

Mental Retardetion

Leprosy CuredA1 - YesB2 - No

g) Council Registration Number RN RM Name of Nursing Council

h) Whether in Service A1 - YesB2 - No

Place of work ..............................................................................................................................................................................................................................

i) Years of experience after RN/RM

27. Details of fee Remittance:

a) Mode of Payment(Pls. write relevantcode in the box)

A1 - Cash ChallanB2 - Demand Draft

b) Amount : Rs. Please add Rs. 500/- in case of Late fee

c) DD/Challan Number:

e) Bank Name:

28. Declaration:I hereby declare that I have read and understood the conditions of eligibility for the programme for which I seek admission. I fulfill the minimum eligibilitycriteria and I have provided necessary information in this regard. In the event of any information being found incorrect or misleading, my candidature shallbe liable for cancellation by the University at any time and I shall not be entitled to refund of any fee paid by me to the University. Further, I have carefullystudied the rules of the University as printed in the Prospectus and I accept them and shall not raise any dispute in future over the same rules. Iunderstand that the University can amend or change any rules without advance intimation and I will be abiding by them.

Place :Date :

Signature of the Applicant

For office use

ADMITTED NOT ADMITTEDReason for not admitting Signature with date

25. Educational Qualifications:

A1 - 12th

B2 - 10th

a) Whether 10th or 12th pass b) Main Subjects1. ____________________2. ____________________3. ____________________

c) Year of Passing f) Board Code/Universityd) Division e) %age of Marks

a) Qualification b) Main Subjects1. ____________________2. ____________________3. ____________________

c) Year of Passing f) Board Code/Universityd) Division e) %age of Marks

26. Relevant Qualifications (which make you eligible for application to the programme) GNM/B.Sc.N

4. ____________________ 01,02,03 or 04 for pass

01,02,03 or 04 for pass

A1 - GNMB2 - BScNC3-Any other

INSTRUCTIONS FOR CANDIDATES1. Please send your Application Form by Registered/Speed Post to School of Health Sciences, IGNOU.2. Last date for receipt of filled in application form is as per advertisement.3. Please retain photo copy of the filled application form for future reference.4. For Detailed instructions please refer Student Handbook & Porspectus.5. Self attested Photocopy of all the relevant certificates of DOB, Category, Employment, Educational Qualification, relevant

Qualification making you eligible for application to programme, Council Registration and Demand Draft must be send along withthis application form.

6. Original Certificates will be verified.7. Fill up the column of E-Mail ID and correct mobile no., otherwise candidate will be responsible for non receipt of

communication.