APPLICATION FOR ADMISSION TO P G DEGREE COURSE IN NURSING (M.Sc. NURSING), KERALA

APPLICATION FORM FOR CANDIDATES BELONGING TO SC/ST Application Fee: Rs. 400/- Government of Kerala Office of the Commissioner for Entrance Examinations APPLICATION FOR ADMISSION TO P G DEGREE COURSE IN NURSING (M.Sc. NURSING), KERALA 2011-12 Note: Please read the prospectus carefully before filling up the Application Form. 1. Name in CAPITAL letters, beginning from the left; initials at the end of name. ( Please insert one letter in each box) 2. Full postal address of the candidate in capital letters (With Pin Code).... Pin Code Please paste a recent passport size photograph of the applicant, with Signature of the applicant, half on the photograph and half on the application 2 (a) Contact telephone number 3. Date of birth in Christian Era STD Code Land phone Day Month Year 2(b) Mobile No. e-mail address 4 Are you an Indian citizen of Kerala origin? (Write YES or NO ) (a) b) 5 Do you satisfy the nativity conditions as per clause 7.1 of the Prospectus? (If YES, obtain relevant certificate as mentioned under clause 7.1.1) Do you claim reservation against the seats reserved for Persons with Disabilities. Write Yes/No. If Yes, attach copy of the Medical Certificate of disability from the District Medical Board obtained within one year before the last date of Application. Register number and year of passing of the B.Sc. Nursing / Post Basic B Sc Nursing (Regular) Degree Examination. (If passed) 6 Total marks secured for all the years of B.Sc. Nursing / Post Basic B Sc Nursing (Regular) Degree Examination. (Attach attested copy of all mark lists). a. Marks secured b. Maximum marks 7 Date of completion of one year internship 8 Name of the College from where B.Sc. Nursing Degree has been completed 9 Name of the University (See Clause 7.2.1 (b)) 10 Details of registration with the State Nursing Council (See clause 7.2.2 & 7.2.3) (a) Write registration number and name of the Council 1

11 Details of experience as per clause 7.2.2 of the Prospectus. Name of the Institution(s) FROM Day Month Year Day Month Year TO (i) (ii) (iii) 12 Do you claim reservation under Scheduled Caste/Scheduled Tribe (Write YES/NO). Attach Community certificate from Tahsildar along with the Application form. a State whether SC/ST and also write the name of the Community under which reservation is claimed 13 Details of Application fee remitted Chalan / Demand Draft Number Date Name of Treasury / Bank 15. DECLARATION 1. I do hereby declare that I have read the various clauses in the Prospectus for Admission to M.Sc. Nursing Courses 2011 and the instructions carefully and I agree to abide by them. 2. I also declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief and that in the event of any information being found false or incorrect or ineligibility being detected before or after the examination, action can be taken against me by the Commissioner for Entrance Examinations. Place: Date: Signature of the Candidate For Office Use Only 2

1 [a] CERTIFICATE OF BIRTH / RESIDENCE (To be issued by the Village Officer/Tahsildar/or any other authority in the local body competent to register birth in Kerala State) As per Clause 7.1.1 (a) of the Prospectus Certified that Shri./Smt./Kum..... is an applicant for the M.Sc. Nursing Entrance Examination 2011-12 and that *he/she I his/her father/mother Shri./Smt...... House... Village... District was born in Kerala. OR* Certified that Shri/Smt./Kum...., an applicant for the M. Sc. Nursing Entrance Examination 2011-12, has been a resident of Kerala State for a period of at least 8 years within a continuous period of 13 years preceding the date of application. Signature of the Village Officer Tahsildar/Birth Registering Authority : Name and Designation : Taluk :. District: Place : Date : (Office Seal) *Strike off which is not applicable OR 1 [b] CERTIFICATE OF EDUCATION (To be issued by the Principal of the Nursing College in Kerala where the applicant studied for B.Sc. Nursing Course) As per Clause 7.1.1 (b) of the Prospectus Certified that Shri./Smt./Kum.. an applicant for the M. Sc. Nursing Entrance Examination, 2011-12, was a student for B.Sc. Nursing course in this College during the period from to. and that he/she has passed his/her B.Sc. Nursing Examination in the year. Place : Date : (Seal) Signature of Principal : Designation : Address : OR In the absence of 1(a) or 1(b), candidate should attach self-attested photocopy of any one of the certificates mentioned below : (i) True copy of the relevant page of the SSLC of the candidate showing the candidate s place of birth in Kerala. (ii) True copy of the relevant page of the SSLC of the candidate s Father/Mother showing the place of birth in Kerala with corroborative evidence proving the relationship between the candidate and the person (father or mother) whose certificate has been produced. (iii) True copy of the relevant page of the passport showing place of birth in Kerala issued by Govt. of India, of the candidate or either of parent with corroborative evidence proving the relationship between the candidate and the person (father or mother) whose true copy of Passport has been produced. (iv) Birth certificate of candidate or his/her, father/mother showing the place of birth in Kerala with corroborative evidence showing the relationship between the candidate and the person (father or mother) whose certificate has been produced. 3

[ 2. COMMUNITY CERTIFICATE (For Scheduled Caste & Scheduled Tribes Candidates only) [Certificate as per Clauses 6.1 of Prospectus] 1.This is to certify that Shri./Smt./Kumari.., Son/daughter of.. of.. House.. village/town,.. Taluk,.. District of Kerala State belongs to the. Caste/ * Tribe which is recognized as a Scheduled Caste/Scheduled Tribe under. The Constitution Ammendment (Scheduled Castes) Order, 1950 The Constitution Ammendment (Scheduled Tribes) Order, 1950 (as amended by the Scheduled Castes and Scheduled Tribes Orders (Amendment) Act, 2002) Certified that Shri./Smt./Kumari (name of person) Son/daughter of. of... House....village/Town. Taluk. District is a member of Malai Araya Christian family converted to Christianity from Hindu Malai Arayan Community, which is included in the list of Scheduled Tribes. 2. Shri/Smt./Kumari. and his/her* family ordinarily reside(s) in Village/Town of District of Kerala State. Signature of Tahasildar : Place : Name : Date : (Seal of Office) *Please delete the words/clause which are not applicable. Note: 1. The term ordinarily resides used here will have the same meaning as in Section 20 of the Representation of the Peoples Act, 1950. 2. In case of X ian converts from SC who have subsequently embraced Hinduism, they should get the following certificate recorded by the Tahasildar below the community Certificate. The certificate is issued after observing the guidelines issued in Government Circular no. 18421/E2/87/SC/ST/DD. Dated 15-12-1987 3. Issue of Community Certificate to Scheduled Caste / Scheduled Tribe will be regulated by Act II of the Kerala (Scheduled Caste & Scheduled Tribe) Regulation of Issue of Community Certificate Act 1996. 4. Certificate to persons belonging to Malai Arayan Commuity (ST) converted to Christianity should be in this form. 4

M.Sc. Nursing 2011-12 COMPUTER DATA SHEET [To be filled and returned with the Application Form] APPLICATION NUMBER WRITE BELOW YOUR COMPLETE MAILING ADDRESS INCLUDING YOUR NAME IN BLOCK LETTERS (Write in Black Ink, using Ball point pen) Do not sign over the PHOTOGRAPH Will be Alloted by the Office of the Commissioner for Entrance Examinations. Signature of the Candidate.Pin Code.. PASTE (DO NOT STAPLE) A RECENT PASSPORT SIZE PHOTOGRAPH Telephone number with STD Mobile Number Note: Read the instructions given below for filling up the data sheet completely & correctly. Please insert one letter/number in a box. Boxes: 1-30: Write your name beginning from Box 1 and your initial(s) at the end of your name, leaving one box blank after name. 31-38: Write your date of birth. 39-40: write KS if Keralite or else write NA, 41-48: Write the Aggregate marks in B.Sc Nursing Examination and maximum marks ( for all the years taken together) 49-51:Write SER, if belongs to Service Category or else write NA 52-53:If you claim reservation under SC Communities, or else write ST. 54-55: Write PD, if claiming reservation under Persons with Disability or else write NA. 56-61: Write Total Length of Internship/ Experience/ Compulsory Govt. Service as on 30.09.2011 62-64: Service candidates should also write LNU for Lecturer in Nursing/ SNO for State Level Nursing Officers/ TGN if Teacher of Government School of Nursing as applicable. 65-70: Write the total length of service as on the last date for submission of the Application form or else write NA. Name in CAPITAL letters Initials at the end of Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Date of Birth KERALITE Aggregate marks in B.Sc Nursing Examination ( for all the years taken together) Write Service Quota Day Month Year KS/NA Marks secured Maximum marks SER/NA 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 Community Reservation SC/ST PD/NA Length of Internship/ Experience/ Compulsory Govt. Service Service Quota Year(s) Month(s) Day(s) LNU/SNO/TGN 52 53 54 55 56 57 58 59 60 61 62 63 64 Total length of service as on 30.09.2011 Year(s) Month(s) Day(s) 65 66 67 68 69 70 For Office Use Only 5

INSTRUCTIONS TO FILL IN THE APPLICATION FORM 1. Read the instructions carefully before filling up the Application Form. There are separate Application forms for General/SEBC/Service candidates and for Candidates belonging to SC/ST communities. 2. Affix your recent passport size photographs. One, on page 1 of the application form and sign it with half the signature on the photograph and half outside it. Affix the second photograph on the Computer Data Sheet, in the space provided. 3. Nativity Certificate : Certificate of Birth/Residence [1(a)], to be obtained from a Revenue officer, not below the rank of a Village officer or Certificate of Education [1(b)] given on the Application form or any other document specified under clause 7.1.1. of the Prospectus 4. Copy of Certificate to prove date of birth should be attached along with Application form. [See Clause 7.3 &10.2.6 of the Prospectus] 5. Attested copies of Pass / Degree Certificate and mark lists of all the subjects in the B Sc Nursing Examination should be attached along with the Application form. [As per Clauses 7.2 and 8.2(c) and (d) of the Prospectus]. 6. All candidates [except Service Quota candidates] may send their Applications duly filled in together with the Original Chalan/Demand Draft for Rs.400/- (drawn in favour of the Commissioner for Entrance Examinations, payable at Thiruvananthapuram ) as fees and all other relevant documents specified under Clause 8.1.2, of the Prospectus, to the Commissioner for Entrance Examinations, Housing Board Buildings, Santhi Nagar, Thiruvananthapuram - 695001, so as to reach him on or before 20.08.2011, 5 pm. (See Clause 9.1 of the Prospectus) 7. Candidates applying for the seats reserved for Service quota should send their filled in applications (along with all documents mentioned under Clause 8.1.3&8.2 of the Prospectus) with necessary Service Certificate from the Head of the Department (DME/DHS) to the controlling officer concerned (Director of Medical Education, Medical College Campus, Thiruvananthapuram, Pin. 695 011 / Director of Health Services, Thiruvananthapuram before the last date and time notified (20.08.2011, 5 pm). The fee for Service Quota candidates (Rs.400/-) should be remitted in the Treasury in the head of Account 0210-03-105-29 and the original Chalan receipt is to be attached along with the Application Form. 8. Incomplete/defective/belated Applications will be rejected summarily. *********** 6

PAYMENT VOUCHER Branch: Date././2011 ORIGINAL (To be attached with the Application) STATE BANK OF TRAVANCORE Remittance made to A/c. No. 67052533871 at Santhi Nagar, Thiruvananthapuram Branch in favour of the Commissioner for Entrance Examinations, Kerala Name of Applicant : Application No. : Course Code : MSN 2011 Category : Quota : Purpose of remittance: Application Fee for M..Sc. Nursing Entrance Examination, Kerala 2011 Amount :Rs.400/- (Rupees four hundred only) Date : Signature of applicant (For Bank use) Receipt No. Received Payment Authorised Signatory Stamp with date Last date of remittance of application fee : 20.08.2011 PAYMENT VOUCHER Branch: Date././2011 DUPLICATE (To be retained by the Candidate) STATE BANK OF TRAVANCORE Remittance made to A/c. No. 67052533871 at Santhi Nagar, Thiruvananthapuram Branch in favour of the Commissioner for Entrance Examinations, Kerala Name of Applicant : Application No. : Course Code : MSN 2011 Category : Quota : Purpose of remittance: Application Fee for M..Sc. Nursing Entrance Examination, Kerala 2011 Amount:Rs.400/- (Rupees four hundred only) Date: Signature of applicant (For Bank use) Receipt No. Received Payment Authorised Signatory Stamp with date Last date of remittance of application fee : 20.08.2011 PAYMENT VOUCHER Branch: Date././2011 TRIPLICATE (To be retained by the Bank) STATE BANK OF TRAVANCORE Remittance made to A/c. No. 67052533871 at Santhi Nagar, Thiruvananthapuram Branch in favour of the Commissioner for Entrance Examinations, Kerala Name of t Applicant : Application No. : Course Code : MSN 2011 Category : Quota : Purpose of remittance: Application Fee for M..Sc. Nursing Entrance Examination, Kerala 2011 Amount:Rs.400/- (Rupees four hundred only) Date: Signature of applicant (For Bank use) Receipt No. Received Payment Authorised Signatory Stamp with date Last date of remittance of application fee : 20.08.2011 7