JSS MAHAVIDYAPEETHA

JSS COLLEGE OF- NURSINGRamanuja Road, Mysuru - 4

(Affiliated to Rajiv Gandhi University of Health Science, Bangalore)(Recognized by lndian Nursing Council& Karbataka State Nursing Council)

Space for photo tob6 affixod pleasestick with adhesivedo not pin

No.

13 94Application for Adrnission to B.Sc. Nursing (Basic) Gourse 20 -20

01. Name of the Candidate in full (block letters)to be entered as found in the certificate ofthe qualifying examination

02. Father's Name/Husband's Name (if married)

03. Name of the guardian & relationship (if Father/Husband is not alive)

04. Permanent address of Father/Husband/Guardianwith Telephone Number, Mobile, email

05. Fresent address of the candidate withTelephone Number, Mobile, Email

06. Religion

07. Whether you belong to Scheduled Caste/Scheduled Tribe/Backward Class (State sect,if you belong to any one of these categories)

08. Occupation of Father/Guardian/Husband

09. Annual lncome of Father/Guardian/Husband

10. a) Date of Birth (in Christian era)

10. b)Place of Birth PlacelTaluklDistrictc) State of domicile

d) Mother tongue

e) l-anguages which you can:

ReadWriteSpeak

11. Are you :

alA citizen of lndian Union?lf not mention nationality

b) Have you applied for Eligibility Certificate Yes No

1 2. Academic particulars

Exam passedat the school/

College

Name & Addressof the

School / College

Name of theBoard/Univ Reg No.

Percentage ofMarks Obtained &

Class/Division

No" of attemptsfor Passing

Year ofPassing

a) SSLCiMatriculation

b) PUC/EquivalentExamination

13. Marks obtained in the Qualifying Examination

Particulars Physics Chemistry Biology English Aggregate Percentage in(Physics, Chemistry, Biology

& English calculate to twodecimalpoints)

Actual marks obtained

Maximum Marks

Percentage of Marks

14. Total marks obtained and percentage of mark secured inallsubjects upto two decimal points

15. Details of enclosures to be bttached to the application:a) One photocopy of the statement of marks of the qualifying examination (10+2) / PUCb) One photocopy of the S.S.L.C. certificate showing the date of birthc) One latest passport size photo duly affixed to the application formd) One photocopy of SC/BC certificate duly certified, if applicable

e) Transfer Certificate

01. I hereby declare that the above information is true and complete and I am aware that if any informationis found to be incorrect or incomplete my application shall be rejected/admission shall be cancelled.

02. I have read and understood allthe provision contained in the prospectus and declare to abide by theseprovisions.

03. I have attached FORM 'A' and photocopies of the following certificates, I have not attached originalcertificates.

a) P.U.C. or 10+2 marks sheet & certificate

b) S.S.L.C. Certificate

c) One passport size photo

d) SC/BC certificate (if applicable)

e) Transfer Certificate

Place :

[iate : Signature of the Candidate

DECLARATION BY THE PARENT/GUARDIAN

I hereby declare that i am aware of the financial obligations of admitting my childArvife at this institutionand I can afford and undertake to pay the tuition and other fees payable to the institution under its rules. I alsoaffirm and endorse the declaration made above by my child/wife.

Place:

Date:Signature of the ParenUGuardian

FOR OFFICE USE

PercentageEMarks

t:]

Eligible/Not eligiblefor admission

Admission is approved/Rejected

Admitted/not admitted