(To be completed by applicant) Name of the Applicant by sparrowjacc


									                                          (To be completed by applicant)
                                                                                                        Applicant has t o
                                                                                                        paste one black and
                                                                                                        white or colour
                                                                                                        photograph attested
                                                                                                        by the Matron or
                                                                                                        Principal in this
                                                                                                        Photo size 2” X2”

Name of the Applicant (in Block Letters)
Married _____________________________________________________________________________
Maiden _____________________________________________________________________________

 Present Address                                                  Permanent Address

 _________________________________________ _________________________________________
 _________________________________________ _________________________________________
 _________________________________________ _________________________________________

Particulars of Demand Draft
Name of the Bank and Place ___________________________________________________________
Demand Draft No. & Date ____________________________________________________________
Amount of the Demand Draft Rs. ______________________________________________________

                                                       OFFICE USE
REGION: ___________________________________________________________________________
REC. NO.:___________________________________________________________________________
REGN. NO. ___________________ DIPLOMA NO. __________________ DATE _______________
EXAM. SEAT NO. ________________ MONTH & YEAR ___________________ MARKS _______
For the candidate trained & registered in other than Maharashtra State: -
1. Whether His / Her School is recognised by Indian Nursing Council (YES / NO)
                   a) Indian Nursing Council Letter No. _______________________________________
                   b) Indian Nursing Council State List Sr. No. _________________________________
2. Letter No. MNC/R/VERI/ ___________ date __________ sent for obtaining N. O. C.
3. Number and date of N. O. C. of the present State Nursing Council _______________________

                                                             Thoroughly Checked by _____________________

       Particulars of the candidate's in the list thoroughly checked by _____________________
Registration & Diploma Certificate despatched Memo No. & Date ______________________
Whether all original Certificates (Except Training Certificate) of the candidate have been
despatched Yes /No
                                                           Despatched by _____________________


Along with this Application you have to submit: -
1. Original Training Certificate (i.e. C form) issued by the authorities of institution where
   trained with date, month & year of commencement & completion of the training period.
2. Original & Xerox copy of School Leaving Certificate / College Leaving Certificate / Transfer
   Certificate, as the case may be.
3. Original & Xerox copy of S. S. C. or equivalent examination passing certificate in case of R.
   A. N. M. candidate & S. S. C. and H. S. C. or equivalent examination passing certificate in
   case of G. N. M. candidate and mark certificate of the said examination respectively.
4. Three passport size 2" X 2" photograph in Nurse's uniform covering 3/4 of the head with the
   cap and duly stamped & signed in front by the Nursing Superintendent or Matron of the
   institution where trained and applicant's name & signature at the back. The attestation of
   Nursing Superintendent or Matron should not deface the face of the applicant. Out of these
   tree photographs one copy has to be pasted on front page of this application from where
   necessary square space is provided.
5. If married an original & Xerox copy of marriage certificate or an affidavit made before the
   Magistrate or copy of Government Gazette including maiden and married names.
6. In case of Basic B. Sc. (Nursing) candidate has to submit the original and Xerox copies of
   degree certificate, passing certificate and mark certificates.
7. Copy of the General Nursing registration & Diploma certificate with renewal serial no. and
   date in case of registration of Midwifery for a registered nurse.
8. Fee of Rest. 250/- for Diploma + Rest. 80/- as postage, packing and forwarding charges by
   Demand draft or in cash if personally paid. (Money Order is not accepted)
For the candidate registered or passed examination of other State Nursing Councils:-
1. Above requirements from No. 1 to 6.
2. Letter from INC stating that your institution was recognized during your training period.
3. Original registration & diploma certificate with their two Xerox copies each.
4. Affidavit of the training and registration particulars mad on Rs. 20/- stamp paper as per
   specimen is available in the Council.
5. Rs. 250/- for each registration & Rs. 100/- as postage, by demand draft or in cash, if
   personally paid.
6. For submitting Registration application presence of the candidate is must.

N. B.: In case candidates registered their nursing qualification other than Maharashtra State has
to submit a letter from the INC setting that his / her School of Nursing / College of Nursing
was recognized by the INC during his / her training period. Also a letter of verification of
registration particulars from the parent State Nursing Registration Council stating that her / his
registration is in force and effect. The verification letter should reach directly to this Council
from the candidate's parent Nursing School on request by Maharashtra Nursing Council.
Verification letter personally deliver by the candidate is not applicable.

                                      FORM 5
                                     (RULE 72)
                        UNDER SUB-SECTION (3) OF SECTION -17

The Registrar,
Maharashtra Nursing Council,
E. S. I. S. Hospital Compound,
Nurse's Hostel, 2nd floor,
L. B. S. Marg, Mulund West,
Mumbai 400080

       I request you to register my name & other particulars as stated below in part.
________________________ Section _______________________ of the register maintained under
Maharashtra Nurse's Act, 1966 & further to give me a certificate of registration.
Name in Full (in BLOCK LETTERS) _____________________________________________________
                                        (Surname) (First Name) (Father's /Husband's Name)
Permanent Home Address (Block Letters) ______________________________________________
Maiden Name & Surname in the case of married women: __________________________________
Nationality                   :      _________________________________________
Place & Date of Birth         :      _________________________________________
Description of qualification of which registration is desired ________________________________
Produced Original Training Certificate & a copy of it issued by the Head of the institution of the
following: -
1.    Date of obtaining institutions of training
2.    (a) Institution or institutions of training

      (b) Period / Period of training

3.    (a) Institution from where appeared for

      (b) Seat No. & Month of examination

4.    I forward herewith the original and copy of
      (i)     My Birth Certificate / Matriculation Certificate / S. S. C. / H. S. C. Examination
             certificate in case of other State candidate's equivalent certificate School Leaving
      (ii)   The ________________________________________ Degree / Diploma Certificate
             which I possess in original & a copy of it.
             (The above documents may please be returned to me when no longer required)
5.    The Registration Fee of Rs. 250/- and postage of Rs. 80/- or Rs. 100/- sent in by Cross
      Postal Order / Demand draft in the name of Registrar, Maharashtra Nursing Council.
6.    I am applying for registration for the first time & I was not registered as a Nurse /
      Midwife Revised Auxiliary Nurse Midwife / Auxiliary Nurse & Midwife / Health
      Visitor under any law in India before date of this application.
7.    I was / have bee registered as Nurse / Midwife / Revised Auxiliary Nurse Midwife /
      Health Visitor under the _______________________________________ (State the Act or
      Law) in the year _______________________ & my registration number is / was _________
8.    I have carefully read the requirements sent with the form. I certify that the particulars
      furnished above are true to the best of my knowledge & belief.

Place: ________________                                      Yours faithfully,

Date: _________________
                                                             (Usual signature)

                               (SPECIMEN OF APPLICATION)

NAME OF THE CANDIDATE:           ______________________________________________________

ADDRESS:    ________________________________________________________________________


TEL. No:    ___________________

The Registrar,
Maharashtra Nursing Council,

                   Sub: Application for registration

      Name of the state Nursing Council _______________________________________________

      Registration Number & Date:        ____________________ Date ____________

      Diploma Number & Date:             _____________________ Date ___________

Respected Sir/Madam,
      I _________________________ Complicated my General Nursing course at Name of the
School _________________________ city ___________ from ___________ to ________________, I
would like to get registration with Maharashtra Nursing Mumbai, as I am seeking employment
in the same state, here with I enclosing the Xerox copies of my registration certificate for
necessary action.

      Thanking you,
                                                       Yours faithfully,

       Date : ____________                             ________________


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