GOVERNMENT MEDICAL COLLEGES AND ASSOCIATED HOSPITALS JAMMU AND KASHMIR Application Form for Renewal of Registration of Nurses Passport size Attested Photo 1. Name in full (Surname first)-----------------------------Ku./Smt./Shri------------------------ 2. Single/ Married/Widow/Separated--------------------------------------------------------------- 3. Age---------------Date of Birth---------------------------------------------------------------------- 4. Permanent Address in full------------------------------------------------------------------------- 5. Present address in full------------------------------------------------------------------------------ 6. Educational qualification--------------------------------------------------------------------------- 7. Where Trained--------------------------------------------------------------------------------------- 8. Date of Registration with Registration No.----------------------------------------------------- 9. Renewal of registration required as GENERAL NURSES/Sr. MIDWIFE/ B.Sc.NURSING /G.N.M./ AUXILIARY-NURSE-MIDWIFE/REVISED------------------- 10. No. of in service training Programme/Seminar/Workshop attended (a) Date----------and Duration----------------------------------------------(b) Place of training------------------- 11. Date of remitting Fee by Bank Draft----------------------------------Dated-------------------- Name of Bank-------------------------------------------------------------Amount------------------ I enclose original registration certificates, which may please be returned to me along with renewal certificate. I hereby undertake that if any registration is renewed, I will, in the practice of my profession as a--------------------------------------observe and be bound by the provision the Act and the rules and byelaws made or order and instructions, issued there under so far as they affect me and that if the Council shall at any time after due enquiry, order my name to be removed from the register. I will return to Registrar the certificate the certificate and badge (if any) issued to me by the council. Date-----------------------------------------------------------------------Place---------------------------------Signature of Applicant and Full Name
