Constant Lievens School of Nursing

APPLICATION FOR REGISTRATION

1. Name (as on Mat. Cert.) :

2. Date of Birth :

3. Age :

4. Height (cm) :

5. Weight (kg) :

Photograph

6. Religion :

7. Culture Background :

8. Permanent Address :

9. Present Address :

10.

Educational Qualification	Total Marks	Year of passing	Division	% of Marks	Certificate
a. Matric
b. I.Sc./I.A./I.Com.
c.

11. Father's Name :

12. Age :

13. Occupation :

14. Mother's Name :

15. Age :

16. Occupation :

17. Guardian's Name if Applicable :

18. Relationship :

19. Occupation :

20. Address :

21. Local Guardian's Name, if Applicable :

22. Relationship :

23. Occupation :

24. Address :

25. Reasons for selecting Nursing as a carrier :

26. Contact Details :

Landline :

Mobile :

E-mail :

DECLARATION

I hereby declare that the statements given in the application are true, and I agree to follow the rules and regulations of the institution subject to change from time to time.

*** Please check the required fields in the registration form.