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B.Sc Nursing Application Form for the Academic Year 2024

    Name of the Student
    (in Block Letters)

    Postal Address with Pincode

    State / Nativity

    Upload Your Photo (Photo size should be below 500kb)

    Country / Nationality

    Mobile No/Land Phone No

    Email Address

    Gender

    Date of Birth & Age

    Blood Group

    Religion & Caste

    Category (Tick Your category)

    Marital Status

    Adhaar Number

    Name, Occupation &
    Mobile No of Father

    Name, Occupation &
    Mobile No of Mother

    Income (Rs.)

    Academic Qualification

    1. SSLC

    2. HSE/CBSE/ICSE/VHSE

    Subjects in HSE/ CBSE/ICSE/VHSE

    Physics

    Chemistry

    Biology

    English

    Co – Curricular Activities

    Year of Passing with Month

    Migration Certificate No

    Admission Quota

    Place of Stay

    If Day scholar, distance from
    Home town to College

    Payment A/C Information

    Name : Palakkad Institute of Medical Sciences
    Bank : AXIS Bank
    Account No : 920010066736358
    Branch : Chandranagar
    IFCE Code : UTIB0003000

    Upload Your Payment receipt

    Upload Your Signature

    Declaration
    I hereby declare that all the statements in this application are true, complete and correct to the best of my knowledge and belief.