APPLICATION FORM FOR POST BASIC DIPLOMA COURSES

Name of the course opted (please tick) :

Name of the Candidate :
(in block letters) :
Mother’s Name :
Date of Birth :
(as per SSC Certificate)
Marital status :
Languages know :
RN & RM number :
Name of the Nursing Council:

Qualifications
GNM/B.Sc. Year of Passing Percentage of Marks

Experience (in chronological order, starting from the most recent one)
Name of the Institute/Organization Work experience in labour room/ Neonatal ICU/ Paediatric ward.
Duration
From To
Work experience in teaching
Duration
From To

Total years of experience
Clinical Teaching

What motivated you to apply for the Post Basic Diploma Course in Nurse Practitioner Midwifery/Neonatal Nursing ?
Permanent Address :
Phone :
Email :
Local Guardian Address (if any) :
Phone :
Email :
Please tick, if you have original copies of below ( To be submitted at the time admission for verification ) :

FERNANDEZ SCHOOL OF NURSING
Stork Home Annexe, Road No. 12, Banjara Hills, Hyderabad, Telangana – 500 034
M +91 8008500598 P 04024760860 | E fsn@fernandez.foundation | W www.fernandezhospital.com

The Indian Nursing Council, New Delhi has recognized FERNANDEZ SCHOOL OF NURSING vide Certificate No. 18-02/5098 – INC
The Government of Andhra Pradesh has sanctioned FERNANDEZ SCHOOL OF NURSING vide G.O. Ms. No. 471 dated 2.11.2004
and Andhra Pradesh Nurses & Midwives Council letter No. APNMC / GNM / 5192 / 2008 dated 28.01.2008

Fernandez School of Nursing, 2021. All Rights Reserved.