(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 square 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 _____________________ 1

REQUIREMENTS FOR OBTAINING REGISTRATION 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) FORM OF APPLICATION FOR REGISTRATION UNDER SUB-SECTION (3) OF SECTION -17 To, 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 exam (b) Seat No. & Month of examination

4.

5. 6.

7.

8.

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 Certificate. (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) 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. 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. 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 _________ 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: ________________ Date: _________________

Yours faithfully,

_______________ (Usual signature)

(SPECIMEN OF APPLICATION) FROM: NAME OF THE CANDIDATE: ADDRESS: ______________________________________________________

________________________________________________________________________ _________________________________________________________________________

TEL. No:

___________________

To, The Registrar, Maharashtra Nursing Council, Mumbai-80. Sub: Application for registration Name of the state Nursing Council _______________________________________________ Registration Number & Date: Diploma Number & Date: ____________________ 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 : ____________

________________