COMBINED COUNCILS BUILDINGS KOTLA ROAD TEMPLE LANE NEW DELHI 110 002 APPLICATION FOR CONSIDERATION AS AD HOC INSPECTOR OF INDIAN NURSING COUNCIL 1 NameBlock Letters ID: 297908
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INDIAN NURSING COUNCIL COMBINED COUNCILS BUILDINGS KOTLA ROAD, TEMPLE LANE NEW DELHI - 110 002 APPLICATION FOR CONSIDERATION AS AD - HOC INSPECTOR OF INDIAN NURSING COUNCIL 1. Name(Block Letters) :__________________________________________ _____ 2. Designation :_______________________________________________ 3. Present Place of Work :_______________________________________________ _______________________________________________ _______________________________PIN__________ ___ 4. Address of Residence :_______________________________________________ _______________________________________________ _______________________________PIN_____________ 5. Telephone Number :(Off.)______________________________________ _____ (Res.)__________________(Mob.)___________________ 6. Whether working in Govt./Pvt :_______________________________________________ 7. Date of Birth :________________________________________________ 8. R.N.R.M. No. :________________ ________________________________ (Attested by Competent Authority) 9. Teaching Experience : a fter B.Sc . (N) : ________________________________________________ a fter M .Sc . (N) : ________________________________________________ 10(a) Educational Qualification (Copy to be attested by Competent Authority). Degree Year University/Institution (b) Professional Qualification: Degree Year University/Institution Self Attested Photograph 11. Experience in Teaching (Appointment/Relieving order attested by Competent Authority to be enclosed) Course Fro m To Name of the Institution A.N.M. G.N.M. B.Sc(N) P.B.B.Sc(N)/ Post Graduate 12. Other Experience: As Examiner Name of the State Council/Board/ Any other From To A.N.M. G.N.M. B.Sc( N) Post Graduate 12.a) I hereby declare that the statements made above are correct to the best of my knowledge. b) I will be available for inspection whenever called to do so. c) I am physically fit to carryout the travel involved in inspection. SIGNATURE OF CANDIDATE (From Management/Head of the Institution) The application of ______________________(Name of the Candidate) for inspector is duly verified and certified. Comments may be given with regard to reliability & character of the candidat e for inspection of Schools/Colleges of Nursing. __________________________________________________________ ___________________________________________________________________________________ ______________________________________________________________ _____________________ Signature_____________________________________ Name of Head of the Institution/Competent Authority_____________________________________ Designation and Official Stamp____________________________________