PROSPECTUS FOR ADMISSION INTO BASIC B.SC NURSING COURSE IN ALL INC/ONMC RECOGNISED

Transcription

1 PROSPECTUS FOR ADMISSION INTO BASIC B.SC NURSING COURSE IN ALL INC/ONMC RECOGNISED GOVT. & PVT. NURSING COLLEGES OF ODISHA FOR THE ACADEMIC SESSION Approved By Govt. in Health & Family Welfare Department No.ME-II-M-65/ /H., Dtd. 04/07/2018 Cost of application form & Prospectus: Rs.500/- (Rupees Five Hundred) only 1

2 Application form and Prospectus for admission into 4 years Basic B.Sc Nursing course for the academic session are available in the official website of the Directorate of Nursing, Odisha i.e. (Click News & Events) during the period from to Candidates seeking admission for the course at Govt. & Private Colleges of Nursing (recognized by the Indian Nursing Council/ONMC) in the state of Odisha may apply in the prescribed application form within the stipulated time.. For any query contact: - Tel No

3 INDEX SL.NO CONTENT PAGE NO I Admission Calendar 4 II General information 4 III Selection Committee Members 4-5 IV Eligibility criteria 5 V Procedure for filling up and submission of application form 5-7 VI Merit list 7 VII Counseling overview 8 VIII Selection Procedure and reservation Policy 9 IX Fee structure X Post admission Annexure I Application Form Annexure II Proforma of Permanent resident certificate 17 Annexure III Proforma of SC/ST certificate 18 Annexure IV Proforma of Ex-service men/service men Certificate 19 Annexure V Proforma of Marriage declaration form 20 Annexure VI Proforma of Undertaking form of Self Declaration by Parent/ Guardian 21 Annexure VII Proforma of Medical Fitness Certificate 22 Annexure VIII SBI Challan Form for Application fee 23 3

4 1 1. TENTATIVE ADMISSION CALENDAR Availability of application form & Prospectus in official website ( Dt to Last date of receipt of off-line Application Dt by 5 P.M 3 Complying of Wanting documents after due Scrutinisation 4 Date of declaration of merit list in the Official web-site of the Nursing ( Dt to excluding Govt. holiday on date Date of Counseling & deposit of course fees Dt to excluding Govt. holiday on date Date of reporting at the concerned institutions for admission both counseling student and vacant seats of 85% Govt. quota seats + 15% Management students Dt Spot Counselling For Govt. Institutions Dt / Dt Date of Commencement of classes for 1 st year Dt II.GENERAL INFORMATION The duration of the course is 4 years which includes theory and practical as per prescribed syllabus of Indian Nursing Council, Newdelhi. All seats in (Govt. college of Nursing & 85% Govt. quota seats of private Colleges) will be filled up through counseling from the Central merit list approved by the state selection committee. The private Institutions will fill-up the vacant seats of 85% Govt. quota seats at their own level by following the eligibility criteria fixed by INC New Delhi. Private institutions will fill up 15% seats under management quota as per eligibility criteria of INC New Delhi. The recognized institutions list (Govt.&Private) will be submitted by Registrar ONMC by and they will be allowed to participate in the counselling for the academic session Both Female and Male candidates are eligible to apply. (10% seats reserved for male candidate.) III.SELECTION COMMITTEE MEMBERS:- The State Selection Committee shall consist of:- 1. Director Nursing, Odisha :Chairperson 4

5 2. Addl. Director Nursing, Odisha :Member 3. Dean& Principal,MKCG,MCH,Berhampur :Vice-chairman 4. Principal, College of Nursing, Berhampur :Member 5. Deputy Director of Nursing, Odisha :Convenor 6. Assistant Director of Nursing (Admin), Odisha :Member 7. Secretary, ON&MEB, Bhubaneswar :Member 8. Registrar, ONMC, Bhubaneswar :Member 9. Section Officer, Nursing, Odisha :Member Co-ordinator IV.ELIGIBILITY CRITERIA Candidate must:- Be of minimum 17 years of age as on Have passed 10+2 or equivalent examination with Science (Physics, Chemistry & Biology) from CHSE, Odisha or any other board or Council or University equivalent thereof. Have passed 10+2 examination in Science (physics, chemistry & Biology) conducted by National Institute of Open School with 45% marks are also eligible to apply. Have passed in the subject of PCB & English individually and must have obtained a minimum of 45% marks taken together in PCB at the qualifying examination i.e. (10 +2). Candidate s belongings to SC/ST the marks obtained in PCB taken together in qualifying examination be 40% instead of 45 % as stated above. English is a compulsory subject in 10+2 for being eligible for admission to B.sc nursing. Have passed odia up to ME standard. For Candidates to be admitted in (Govt. /85% Govt. quota seats in INC/ONMC recognized private) institutions. Be either domicile/ permanent resident /native of Odisha but currently residing outside Odisha ( candidate seeking admission in Govt. College of Nursing, and 85% of Govt. quota seats in Private INC /ONMC recognized institutions) Be medically fit to undergo the course. Loco motor disability of lower limbs between 40% to 50% only will be taken into consideration for Physical handicapped category. Candidates are advised to obtain their handicapped certificate from the competent authority of the concerned district. V. PROCEDURE FOR FILLING UP AND SUBMISSION OF APPLICATION. All applicants are advised to go through the Prospectus thoroughly before filling up the application form. Candidate must apply in the prescribed application form along with requisite fees and Self attested photocopies of the documents/testimonials. The application form must be filled up by the candidate and signed at the appropriate 5

6 column. Incomplete Application will be summarily rejected. Application form Overwriting/cutting/ineligibility are also liable to rejected. If ineligibility of a candidate is detected at any stage before or after publication of merit list/ counseling/admission, his/her candidature/admission will be cancelled without any notice. In case any candidate is found to have furnished false information or certificate etc. or is found to have withheld or concealed any information in his/her application, he/she will be debarred from admission. It is the responsibility of the candidate to ensure that correct details including address, Id, contact number is filled in the Application Form. The Convenor will not be responsible for any loss in transit or for incorrect address given by the applicant in the Application Form. Payment of application fees will be accepted in shape of SBI Challan not through any other mode. (Challan form can be downloaded from ANNEXURE-VIII of the prospectus). No candidate is allowed to submit for more than one application. The following Documents are to be furnished by the candidate along with the application form a) Self-attested photocopy of 10 th (HSC) or equivalent examination mark sheet& pass certificate. b) Self-attested photocopy of (10+2) Science (PCB&E) mark sheet & pass certificate issued by CHSE, Odisha or equivalent thereof. c) Self-attested photocopy of conduct /character certificate from the head of the institution last attended. d) Colour passport size photograph (5cmx7cm approximately) self attested on front side should be affixed at the space provided in the application form. e) Self-attested photocopy of the resident certificate (Must have been issued within 06 month prior to the date of Advertisement 07 th July 2018)/nativity certificate from the competent authority (Refer Annexure-II). f) In case of SC/ST candidates, self-attested photocopy of the caste certificate from the competent authority (Refer Annexure -III). g) Self-attested photocopy of physically handicapped certificate from the competent authority (For Loco motor disability of lower limbs between 40% to 50% physically handicapped candidates.). h) Self Attested photocopy of passing Odia as a subject at M.E / HSCE issued by Board of secondary education or other equivalent board. i) Self-attested photocopy of the certificate issued by the Rajya Sainik Board. ( In case of candidates claiming seats reserved for Children of Ex-Serviceman & for children of Serviceman from the competent authority of defense category only, Refer Annexure IV) 6

7 VI. j) Marriage declaration in the prescribed form applicable for married candidates. (Annexure- V) k) Self attested photocopy of Green Card (with all pages) issued by the Chief District Medical Officer. ( Candidates claiming seats reserved under Green Card quota) The name and Date of birth in green card should match with the name and Date of birth mentioned in the HSE/equivalent certificate. Any difference regarding this should be supported by an affidavit duly sworn in before the executive magistrate. l) Original challan deposit slip of SBI Challan of Rs.-500/- towards application fees (Refer Annexure VIII). Candidates are required to send application along with required documents which should reach this Address Convenor, Basic B.Sc Nursing Selection Committee, Odisha, O/o the Directorate of Nursing, Heads of Deptt. Building, Bhubaneswar, Khorda, Odisha, Pin on or before by 5 PM. a. Applicant has to send application through Regd.Post/Speed Post. The envelope containing the application shall be prominently super scribed Application for Admission into Basic B. Sc. Nursing b. Applications received after due date & time shall be summarily rejected. C. Incomplete applications /application without requisite documents shall be summarily rejected. d. No candidate is allowed to submit more than one application. e. The cost of application fee is non-refundable. MERIT LIST The merit list will be prepared on the basis of career marks. For career marks, 50% of the aggregate marks secured in HSC/10th & 50% of the aggregate marks secured in Physics, Chemistry, Biology in 10+2 /12 th examination will be taken together. For example: (if in 10 th examination 60% mark secured and in (Physics+ Chemistry+ Biology = 50% of mark is secured then career marks will be =55 marks ) In case of candidates having equal marks in aggregate on the above career marking, inter-se-merit shall be decided as follows. 1 st. -- According to the total marks secured in Biology at the qualifying Examination. 2 nd. --- In case of a further tie, according to the total marks secured in English at the qualifying examination. 3 rd. --- In case of a further tie, candidate senior according to the date of birth will be considered. Eligible candidates as per their merit will be directed to appear before the Selection Committee on the schedule date, time and venue for counseling and admission. The merit list will be prepared Male/Female separately for the following category. SC (Schedule Caste) 7

8 o ST ( Schedule Tribe) o Physical Handicapped o Green card holder (GCH) o Ex-Serviceman o Unreserved VII. COUNSELLING OVERVIEW The Date, Time & Venue of the counseling will be notified in the official website of the Directorate of Nursing ( ). Intimation letter will be also sent to the candidate in his/her address. In case the candidate fails to receive the intimation by post/ download from the website, he/she may collect a copy from the Convenor ( Dy. Director Nursing) in any working day between 10 A.M- 5 P.M during the pre-counselling period. Candidates are required to attend counseling on the scheduled date and time. No representative in his/her favour for the purpose shall be entertained. Counseling and admission against reserved category will be done at beginning. If a Candidate fails to attend counseling on the scheduled date will not be allowed for admission during the session Once the candidate has opted for a seat in any institution, he/she will not be allowed to change the option. Spot Counseling for Govt. Institutions The Spot Counseling will be done within the stipulated period as per INC, if the seats in the Govt. institution will remain vacant. The Convenor will prepare the waiting list for spot counseling and the counseling will be completed by the last week of October. Documents to be produced by the candidate at the time of counseling and admission. All the documents in original mentioned in page no: 6 would be verified during the counselling with regard to the facts and figures furnished in the application in support of her / his candidature. Claims for admission would be rejected if the original certificates and documents are not submitted by the candidate at the counselling spot. Undertaking for extension of time to submit the original certificates and documents will not be entertained under any circumstances. N.B: Candidates are required to submit CLC/TC /Migration Certificate and Medical Fitness Certificate during the time of counseling. In case of non availability of these aforesaid documents i.e CLC/TC /Migration Certificate, the candidate shall submit an undertaking that he/she will submit the original CLC/TC /Migration Certificate at the concerned institution during the time of reporting. Claims for admission shall be rejected if the original certificates/documents are not submitted by the candidate at the time of admission in the concerned Institution. No undertaking in this regard will be accepted. 8

9 Undertaking as per Annexure VI of this Prospectus, signed by the parent/husband/guardian/ local guardian of the candidate shall be submitted. Applications for change of training institution during the training period are not permissible at any circumstance. Spot Counseling for Govt. Institutions - The Principal of the respective Govt. Nursing Institution will report immediately (through an ) about the vacant seats of any course to the Chairperson of the state Selection committee-cum-director of nursing, Odisha from the last date of reporting of the students. The Said vacant seat is to be filled up through spot counseling before cutoff date of the admission process. VIII. SELECTION PROCEDURE AND RESERVATION POLICY (Common to all colleges of Nursing): a) 22.5% for ST ( Scheduled Tribe) b) 16.25% for SC ( Scheduled Caste) c) 3% each for PH (Physical Handicapped) d) 5 % GCH (Green card Holder) e) 3% for Children of Service man & Ex-Service Man) f) 10% reservation for male candidate out of the total seats as per the reservation policy. N.B: Seat inter-convertibility: In case the seats reserved for SC category will not be filled up because of non availability of candidates belonging to the particular category the vacant seats will be filled up by the candidates belonging to Scheduled Tribe category and vice versa. In case candidates do not qualify from the SC/ST category, vacant seats will be filled by the candidates from the general category. Similarly, in case the seat remains vacant against any reserved quota then these seats shall be filled by the candidates from the general category. NOTE. I All reserved category candidates who qualify in the common merit list can attend the counselling for unreserved category seats and exercise her/his option. Her/his candidature will be considered as per the position in the common merit list. IX.FEE STRUCTURE The following fees are to be deposited at the time of admission into 1st Year/2nd Year/3rd year /4th year Basic B. Sc. Nursing Course. 9

10 Fees for Admission into 4 years Basic B.sc Course at Government College of Nursing Sl No. Name of the Institution 1 Govt. College of Nursing Admission fees 1 ST Year 2 nd Year 3 rd Year 4 th Year 01 Admission/Tuition Rs Rs Rs Rs fee 02 Caution Rs Money(Refundable) 03 University Athletic Rs Rs Rs Rs fee 04 University cultural Rs Rs Rs Rs fee 05 Youth Red cross fee Rs Rs Rs Rs University Rs Registration fee 07 University Rs Recognition fee 08 Student Aid fund Rs (SAF) 09 Hostel Rs Rs Rs Rs fee(electricity 10

11 charges)(not applicable for Male students) 10 Water charges Rs Rs Rs Rs TOTAL Rs.18, Rs.17, Rs.17, Rs.17, Course Fees for 85% Govt. quota Seats under Private Institutions Fees 1st Year 2nd Year 3rd year 4th year Tuition Fee/Admission Fees Rs.42,000/- Rs.42,000/- Rs42,000/- Rs.42,000/- TOTAL Rs.42,000/- Rs.42,000/- Rs.42,000/- Rs.42,000/- Besides the above, the hostel fees, electric charges, University registration & examination fees & other college/institution dues etc shall be paid extra by the candidate. Deposition of Part-Course fees under 85% of Govt. quota seats in private Institutions The candidates those will be selected for admission into Basic B.sc Nursing Course under 85% of Govt. quota seats in private nursing Institutions, they have to pay Rs.20,000(Twenty thousand rupees only)to the concerned Institution as a Part course fees during the time of counseling. POST ADMISSION. a. STIPEND AND SCHOLARSHIP Candidates admitted in Govt. College of Nursing. Will be paid P.M during internship. SC / ST candidates for admission into B.Sc. Nursing Course in private recognized institutions in the State will get Scholarship by NHM, Government of Odisha under Public-Private Partnership (PPP) scheme titled Swasthya Sebika Nijukti Yojana,Subject to approval of competent authority /funding agency as under:- - Partial Scholarship as tuition fees to SC/ST candidates in non-kbk districts for B.Sc. Nursing. Per Rs.15, 300/- per annum. - Full Scholarship as tuition fees to SC/ST candidates in KBK + districts for B.Sc Nursing. Per Rs.50, 000/- per annum. - Sponsored SC / ST candidates have to execute a bond with Government which will be provided during admission subject to provision of funds by the appropriate authority. - b. DISCONTINUANCE DURING STUDY PERIOD 11

12 In case of discontinuance from study on any ground the stipend already received, will be recovered in full as per the provisions of the Agreement. c. HOSTEL ACCOMMODATION: Hostel accommodation shall be provided to the female candidates at Govt. College of nursing by the Principal as per merit and subject to availability. There is no provision of hostel for male candidates in Govt. College of Nursing and they are required to stay outside in their own arrangement. The hostel fees including electric charges will be excluded out of the total fees for male candidates in Govt. Institution. In case of availability of such accommodation facility in any Govt. institution, the candidates have to pay the actual fees as mentioned in prospectus. Hostel provision for male candidates of Private Nursing Colleges is optional. In exceptional circumstances, outside hostel accommodation for married women candidates will be considered by the Director of Nursing, Odisha keeping in view the genuineness of the case. In case of pregnant women will be allowed to prosecute the nursing course, on the following condition; o She may avail six months maternity leave during study period for welfare of the child but she can t appear the examination in that year. o After six months she will be eligible to appear the exam for prosecuting the same course and the course completion will be extended by six months. UNIFORM : Selected candidates after admission have to wear uniform: o Female candidates have to wear bottle green Saree / Salwar and Punjabi during field duty, and white colour Saree, Blouse / Salwar and Punjabi with white Coat during clinical duty. o Male candidates have to wear bottle green trouser and shirt during field duty and white colour trouser and shirt with white coat during clinical duty. Vacation and Holidays regulated as per INC/University guidelines from time to time. The state selection committee members have decided calendar of events as per INC file No /2018, dated , as follows; Winter Vacation B.sc Nursing 20 th December 2018 to 3 rd January 2019 Summer Vacation B.sc Nursing 20 th may 2019 to 19 th June 2019 *Dussahara puja Vcation according to calendar in each year for all courses. (B.sc nursing for 15 days). *As regards examination schedule for the nursing course of Basic B.sc Nursing, the concerned University will decide at their level. 12

13 *Preparatory leave for the examination One week before the examination schedule fixed by the university. DISCIPLINE: Students remaining absent beyond 15 days in addition to the prescribed leave will not be allowed to re-join, except in unavoidable circumstances;i.e Natural Calamities Any accidental case Tuberculosis Heart disease Renal disease AIDS Psychiatric disease The principal of the respective institution will report about the students detail to the Chairperson Cum-Director of Nursing, Odisha in time. Other Condition- In other exceptional cases, Chairperson Cum-Director of Nursing, Odisha will be empowered to decide. Candidates got admitted should abide by the Rules and Regulations of the College, Hostel & concerned University/examining body. Those found disobeying the Rules and Regulations shall be debarred from the Hostel and College without any notice. AS PER DIRECTION OF HONOURABLE SUPREME COURT OF INDIA PASSED IN SLP (C) No.24295/2004, SLP No.14356/2005, WPC No.173/2006 AND SLP (C) No /2004. IF ANY INCIDENT OF RAGGING COMES TO THE NOTICE OF THE AUTHORITY, THE CONCERNED CANDIDATE SHALL BE GIVEN LIBERTY TO EXPLAIN AND IF HER / HIS EXPLANATION IS NOT FOUND SATISFACTORY, THE AUTHORITY WOULD EXPEL HER / HIM FROM THE INSTITUTION. o Ragging in all forms in the Nursing Institution is strictly prohibited; The Institution has to take immediate appropriate action in this matter. Affidavit (1) by the candidate (2) by the parent shall be taken as per the circular No.22-1 O (Web)-INC (Part) dated 14th May o In case any dispute in respect of the stipulation in this prospectus and admission of students, the interpretation and decision of the admission committee shall be final and binding. o In case of legal disputes the counter/p.w(c) will be filled by the convener on behalf of selection committee/govt. IMPORTANT INFORMATION FOR ALL INSTITUTIONS All the admission process is to be completed on or before 31/10/2018. The time line cannot be changed without permission of INC/GOVT.All the institution have to submit the admitted students list within one month from the last date of admission i.e Dt to and only those students after due verification of their testimonials by the Convenor, then they will be considered as genuine student as per resolution F. no.1 5/2014 INC on dated 29/10/

14 ANNEXURE- I APPLICATION FORM FOR BASIC B. Sc. NURSING COURSE Note: To be filled in by the candidate. (1) FULL NAME OF THE CANDIDATE AS RECORDED IN THE H.S.C.E OR EQUIVALENT EXAMINATION. (In block letter) (2) Sex : (3) CATEGORY CLAIMED GENERAL / S.C./ S.T./ P.H./ Green Card Holder / Ex Servicemen or Servicemen (Put Tick mark whichever is applicable & mentioned the category). (4) Date of Birth.. (As recorded in H.S.C. or equivalent examination) (5) Age as on of the year of Admission (6) Nationality (7) Married / Unmarried.. (8) Religion. (9) Educational Qualification (10) Permanent home Address:- Affix a passport size photograph attested by a Gazetted officer on the Village / Town P.O Police Station Tahasil - Dist State:.. Pin (11) Present Address.. (For correspondence) 14

15 .. Personal Contact no Id (12) Full Name of Father / Husband / Guardian (if father is dead) Occupation. Address.. (13) SBI Journal No (14) Academic Details: (15) Name of the Examination (+2) Science or its equivalent Name of the University / Council / Board Sl No. Name of the Examination Name of the Board/University/council/equivalent thereof Marks Without Ext. Opt. Percentage of Marks without Ext. Opt. 50% of the marks secured 1. HSC or equivalent (16) Marks secured in (10 + 2) Science Examination SUBJECT TOTAL MARK PERCENTAGE 50% OF THE MARKS SECURED PHYSICS CHEMISTRY BIOLOGY GRAND TOTAL Marks in English Secured mark (17)Documents and Certificates enclosed 15

16 (i) (ii) (iii) (iv) (v) (Put Tick mark) Self Attested copy of H.S.C.(10 th ) or equivalent examination(10 th ) pass Certificate& Mark sheet issued by Board of Secondary Education or other equivalent Board as proof of age. Self Attested true copy of mark sheet &pass certificate of qualifying examination (10+2) issued by the C.H.S.E. / Board / University/Equivalent thereof. Self Attested copy of the conduct / character certificate issued by the Head of the Institution last studied. Self Attested copy of certificate in support of category claimed (S.C./S.T. /Physically Handicapped/Ex-Servicemen or Servicemen/Green Card Holder) Self Attested copy of Residential (Must have been issued within 06 month prior to the date of Advertisement 07 th July 2018)// Nativity for candidate who claims as permanent resident of Odisha. Yes / No Yes / No Yes / No Yes / No Yes / No (vi) Self attested copy of Marriage declaration in prescribed form applicable for married candidates. Yes / No (vii) (viii) Self Attested copy of passing odia as a subject at M.E / HSCE issued by Board of secondary education or other equivalent board One attested copy of recent passport size photographs affixed in the space provided in the application form Yes / No Yes / No (ix) Original Department s slip portion of SBI Challan of Rs.500/- Yes / No I declare that the above statement of particulars furnished by me are true in all respect and as such, I undertake that if subsequently, I will be found to have given wrong information with regard to the marks, certificates and documents produced by me in connection with my admission, then my name will be immediately removed from the College in addition to whatever legal action that be taken against me, I agree to abide by the rules of the College / Hostel and pay all fees and deposit all other dues as laid down in the College. I certify that I have not been prosecuted or convicted for any criminal offence involving moral turpitude. Date Full Signature of the Applicant Countersigned by Parents / Guardian / Husband Name. Date 16

17 ANNEXURE II PERMANENT RESIDENT CERTIFICATE FOR BASIC B.Sc. NURSING COURSE Office of the..... Miscellaneous Certificate Case No.... of 2018 This is to certify that Sri / Smt. / Miss /... Son / Daughter / Wife / of Sri is a native of the district of.. in the State of Odisha and he / she belongs to P.S... Tahasil.. The certificate is being granted only for the purpose of Basic B.Sc. Nursing Course Odisha. Full Signature of the applicant Signature of Revenue Officer Date Round seal of the Office Designation (with seal of officer) NOTE: - 1. Revenue Officer means the Chief Officer in charge of Revenue Administrative in the District, Sub-Division of Tahasil & includes Additional Magistrate and Additional Tahasildar. 17

18 ANNEXURE III SC/ST CERTIFICATE BY BIRTH FOR BASIC B.SC NURSING COURSE This is to certify that Sri / Smt. / Miss Son/ Daughter / Wife of Sri of Village / Town P.S.. Tahasil in the District of in the State of Odisha belongs to the. Caste / Tribe which is recognized as Scheduled Caste / Tribe and under Constitution (Scheduled Caste) order 1950 / the Constitution (Scheduled Tribe) order, 1950 as amended by the Scheduled Castes and Scheduled Tribes (Amendment) orders Act The place of birth of Sri / Smt. / Miss.. is of Village / Town P.S. Tahasil. in the District of. of the State of Odisha. Full Signature of the applicant Signature of Revenue Officer Date Round seal of Office Designation (with seal of officer) 18

19 ANNEXURE IV CERTIFICATE OF EX-SERVICEMAN / SERVICEMAN FOR BASIC B.SC NURSING COURSE Name of the ex-serviceman / Serviceman : 2. Permanent address as per service records : 3. Rank in Defense Service : 4. Last place of posting (in case of Ex-Servicemen) : 5. Present place of posting (in case of serving personnel) : 6. Full name of the candidate : 7. Relationship of the ex-serviceman / Serviceman with the candidate : Full Signature of Station Commander / Officer Commanding / Officer-in-Charge / Secretary, Zilla / RajyaSainik Board Full signature of candidate s Parent Designation with Seal of Office Date - 19

20 ANNEXURE V MARRIAGE DECLARATION FORM 1. I, Sri/Smt/Kumari declare as under:- i) That I am unmarried /a widower/a widow ii) That I am married and have only one wife living iii) That I am married and my husband has no other living wife, to the best of knowledge. iv) That I am married to a person who has already one wife or more living. Application for grant of exemption is closed. Recent colour passport photograph of the spouse duly attested 2. The details of my spouse are : a) Name: Sri/Smt b) Date of Birth of the Spouse is / / c) Date of Marriage is : / I solemnly affirm that the above declaration is correct and I understand that the event of the declaration being found to be incorrect after my joining in Basic B.sc Nursing course for the academic session I shall be liable to be rejected of my candidature. Date: Signature (in full) Name in CAPITAL Letters: Note: Please delete clauses which are not applicable. Applicable in case of clause ( i), (ii), (iii),and (iv) only. Please fill Sl No. 2 only if you are married. 20

21 ANNEXURE VI UNDERTAKING FORM SELF DECLARATION BY PARENT /GUARDIAN (To be submitted by the selected candidates at the time of admission) I Sri /Smt.. Name of the Local Guardian (Address of the Local Guardian).. Undertake to act as the Local Guardian of Miss / Smt./Sri Daughter / Wife / Son/Ward of Sri / Smt.. During her / his period of study in the College of Nursing,.... I also undertake to act on behalf of the parents / husband of the said candidate during the period of study in the College of Nursing,... for which I have been empowered by the parent / guardian / husband of the said candidate. I further undertake to take custody of the above candidate if and when required by the College authorities and to ensure that she / he maintains the academic discipline and good conduct during the period of study in the aforesaid institution. Place -.. Signature in full of the Local Guardian Date - ATTESTATION BY PARENT / HUSBAND / GUARDIAN The above undertaking has been signed in my presence, I empower Sri / Smt....to act as Local Guardian of my daughter/wife/son/ Ward, Miss/ Smt./ Sri.. during the period of her/his candidateship in the College of Nursing.... Place -. Date - Signature in full of the Parent / Guardian / Husband Signature in full of the Candidate 21

22 ANNEXURE-VII MEDICAL FITNESS CERTIFICATE CERTIFICATE OF PHYSICAL FITNESS IN RESPECT OF SELECTED CANDIDATES FOR ADMISSION INTO BASIC B.SC NURSING COURSE FOR THE SESSION Name of the Candidate in full Age, Sex Male/Female(Put Tick mark( ) whichever is applicable, Height., Weight.,Heart., Eye, Teeth.., Liver.., Lungs, Spleen..,Blood Pressure.., Any Loco motor disorder, Neurological disorder, Blood Group Please indicate if Pregnant (In case of Female Candidate). Date of L.M.P. (In case of Female Candidate).. Previous Medical History, if any.. Personal Remarks of Identification I certify that I have examined the above named candidate and cannot discover that she has any diseases, constitutional weakness or bodily infirmity and I consider that the candidate is physically and mentally fit to undergo BASIC B.SC NURSING Nursing course. SIGNAURE OF THE CANDIDATE Designation Date with Seal NOTE: - 1. This certificate is to be detached for submission only by the selected candidates on the date of counselling. 2. This certificate must be obtained from the Govt. medical officer not prior to 15 days of the counselling date. 22

23 BANK S SLIP STATE BANK OF INDIA (POWER JYOTI ACCOUNT) CHAIRMAN, BASIC B.Sc. Nsg. SELEC. COMM. & DIRECTOR NURSING,ODISHA ACCOUNT No Name of candidate:- Branch Name Branch Code Amount Rs. In words.. Rupees only ANNEXURE VIII SBI CHALLAN CANDIDATE S SLIP STATE BANK OF INDIA ( POWER JYOTI ACCOUNT) CHAIRMAN, BASIC B.Sc. Nsg. SELEC. COMM. & DIRECTOR NURSING,ODISHA ACCOUNT No Name of candidate:- Branch Name Branch Code Amount Rs. In words..rupees only Journal No.... (To be filled by Bank) DEPARTMENT S SLIP STATE BANK OF INDIA (POWER JYOTI ACCOUNT) CHAIRMAN, BASIC B.Sc. Nsg. SELEC. COMM. &DIRECTOR NURSING,ODISHA ACCOUNT No Name of candidate:- Branch Name Branch Code Amount Rs. In words..rupees only Journal No.... (To be filled by Bank) Journal No (To be filled by Bank) Sign. Candidate Sign. Bank Off. Sign. Candidate Sign. Bank Off. Sign. Sign Candidate Bank Off. Fees remitting Branch may collect Rs. 50/-( Rupees Fifty) only towards non-home charges from the remitter separately 23

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