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SN ALLOTED PSC NAME REPORTING CENTRE NAME

1 District Hospital, Bhind Health and Wellness Centre Cell Second Floor, Annexure Building National Health Mission 8, Arera Hills, Jail Road Bhopal-462004 Phone: 0755-4020145

2 District Hospital, Dhar

3 District Hospital, Ratlam

4 District Hospital, Shivpuri

5 GNMTC, Datia

6 GNMTC, Dewas

7 GNMTC, Jhabua

8 GNMTC, Mandsaur

9 GNMTC, Rajgarh

10 Government College of Nursing, Ujjain

11 RHFWTC Gwalior

12 SIHMC Gwalior

13 District Hospital, Sagar Government Rani Durgawati College of Nursing South Civil Lines Jabalpur 482001 Phone: 076126 20216

14 District Hospital, Satna

15 District Hospital, Shahdol

16 Government College of Nursing, Jabalpur

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ROLLNO NAME ALLOTED PSC NAME ALLOTED

CATEGORY

220609993 SUSHMA SINGH Government College of Nursing, Jabalpur OBC/X/OP

200608580 POORNIMA KRIPALANI GNMTC, Mandsaur OBC/X/OP

190606560 SONU SOLANKI District Hospital, Ratlam UR/X/OP

190601924 ROSHNEE MOHANE GNMTC, Dewas UR/X/OP

200609588 RITA TAGRIYA GNMTC, Jhabua UR/X/OP

906120314 SALMA KHATOON District Hospital, Sagar UR/X/OP

190605784 KIRTI CHOUHAN District Hospital, Ratlam UR/X/OP

190608937 SAPNA SEN GNMTC, Rajgarh UR/X/OP

190608008 SOMYA PANDEY District Hospital, Dhar UR/X/OP

200608227 MAYA KUMAR Government College of Nursing, Jabalpur UR/X/OP

190605562 POOJA DESHMUKH Government College of Nursing, Jabalpur UR/X/OP

190606283 ANAMIKA RAJENDRAN District Hospital, Sagar UR/X/OP

200609592 ARCHANA DEVI PATEL District Hospital, Shahdol OBC/X/OP

200608658 MEENAKSHI Government College of Nursing, Jabalpur OBC/X/OP

210609287 KAJAL MAHAJAN District Hospital, Dhar UR/X/OP

220609957 KANCHAN CHOUDHARY RHFWTC Gwalior OBC/X/OP

190604244 NEHA PANWAR District Hospital, Ratlam UR/X/OP

220609242 KIRAN RAJAK District Hospital, Satna OBC/X/OP

200608659 SAVITA NARWARE GNMTC, Jhabua UR/X/OP

200608856 SARIKA PATHAN District Hospital, Dhar UR/X/OP

190604193 RUKSHAR BEGAM District Hospital, Shahdol OBC/X/OP

190608044 GOURI SENDRE District Hospital, Satna OBC/X/OP

190604257 ROSHNI VIDEHI District Hospital, Sagar UR/X/OP

190606669 DEEPIKA SIHMC Gwalior UR/X/OP

200608540 TARA DUBEY SIHMC Gwalior UR/X/OP

220609447 NISHA KUSHWAHA SIHMC Gwalior UR/X/OP

190608129 DIVYA BHARTI JOSHI SIHMC Gwalior OBC/X/OP

190603517 KIRAN SINGOUR SIHMC Gwalior OBC/X/OP

190608080 DEEPA JAISWAL District Hospital, Shivpuri UR/X/OP

190607988 VARSHA SEN District Hospital, Shivpuri UR/X/OP

190607511 LALITA RATHOR District Hospital, Ratlam OBC/X/OP

190603485 HEMA RAO DHANDE District Hospital, Shivpuri UR/X/OP

200608442 NILOFER KHAN District Hospital, Bhind UR/X/OP

190606105 POONAM PATEL SIHMC Gwalior OBC/X/OP

220609497 ROSHANI TIJARE GNMTC, Rajgarh UR/X/OP

200608573 NEETU CHATURVEDI GNMTC, Datia UR/X/OP

190604899 KEERTI NARWARIA District Hospital, Bhind UR/X/OP

200608741 ANJUSHA BISEN GNMTC, Datia UR/X/OP

190607805 MONIKA DHAKAD GNMTC, Datia UR/X/OP

3

190608885 RANJANA GEHLOT District Hospital, Dhar OBC/X/OP

190604219 NIRDESH KUMARI GNMTC, Rajgarh UR/X/OP

200608722 ANJANA SINGOUR District Hospital, Shivpuri UR/X/OP

200609679 PRIYANKA District Hospital, Ratlam OBC/X/OP

190608892 RAGINI PATEL GNMTC, Rajgarh UR/X/OP

190608392 AJRUN NISHA District Hospital, Shivpuri UR/X/OP

190608248 AYUSHI VISHWAKARMA District Hospital, Shivpuri UR/X/OP

190608442 SHWETA SAXENA District Hospital, Shivpuri UR/X/OP

190601666 SUNITA PATIDAR GNMTC, Rajgarh OBC/X/OP

220609212 HEENA MULEWA GNMTC, Rajgarh OBC/X/OP

190607431 NEHA SONI GNMTC, Rajgarh OBC/X/OP

906130536 SANTOSH KUMARI DWIVEDI District Hospital, Bhind UR/X/OP

190604761 ANITA DANI District Hospital, Shivpuri UR/X/OP

220609317 RITU BONDRE District Hospital, Shivpuri UR/X/OP

220609858 GAYATRI District Hospital, Shivpuri UR/X/OP

200608347 NEHA GUPTA District Hospital, Shivpuri UR/X/OP

220609505 NIRASA PANCHSWR District Hospital, Bhind UR/X/OP

190604747 DEVEE DESHMUKH District Hospital, Shivpuri UR/X/OP

190608729 JYOTI PAWAR District Hospital, Bhind UR/X/OP

190602995 SHARADA SINGH KUSHWAHA District Hospital, Shivpuri UR/X/OP

190604882 KHUSHBU RATHORE District Hospital, Bhind UR/X/OP

220609579 NEHA CHOURASIYA District Hospital, Shivpuri UR/X/OP

220609805 RACHNA SAHU District Hospital, Bhind OBC/X/OP

200608950 DIVYA NAMDEV District Hospital, Shivpuri OBC/X/OP

190606970 ANAMIKA PATEL District Hospital, Shivpuri OBC/X/OP

190606554 POOJA JANGHELA District Hospital, Bhind OBC/X/OP

190608281 NAMRATA NAMDEV District Hospital, Bhind OBC/X/OP

220609724 ANJANA PATEL District Hospital, Bhind OBC/X/OP

220609956 URMILA SIHMC Gwalior SC/X/OP

906130486 PREETI BAGIYAR SIHMC Gwalior SC/X/OP

190607452 REENA RAVIDAS District Hospital, Shahdol SC/X/OP

220609918 ARCHANA FULEKAR GNMTC, Mandsaur SC/X/OP

906130565 RAJNEE AMRWANSHI RHFWTC Gwalior SC/X/OP

190606452 RAJNI PRAJAPATI GNMTC, Jhabua SC/X/OP

200608715 POOJA NIKOSHE GNMTC, Jhabua SC/X/OP

190608420 JAYANTI District Hospital, Shivpuri SC/X/OP

190606258 MALTI URAIYA District Hospital, Shivpuri SC/X/OP

220609116 POOJA ARYA District Hospital, Shivpuri SC/X/OP

190606493 VANDANA GHUDAWAD District Hospital, Ratlam SC/X/OP

220609702 SHAHANAJ BEE GNMTC, Mandsaur SC/X/OP

190608933 DIKSHA RAO District Hospital, Dhar SC/X/OP

190606507 MONIKA KORI District Hospital, Shivpuri SC/X/OP

906130652 MAMTA GAHALOT District Hospital, Bhind SC/X/OP

Scanned by CamScanner

99

INDIRA GANDHI NATIONAL OPEN UNIVERSITYMAIDAN GARHI, NEW DELHI-110 068

APPLICATION FORM(To be submitted to School of Healh Sciences along with the consolidated details of data of each selected student in Hard and Soft copy by MOHFW)

APPLICATION NO.

Enrolment No. (For Office Use)

INSTRUCTIONS1. Please read the instructions before filling up the form (Appendix 26).2. Please use Black/Blue Ball Point Pen in boxes using English CAPITAL LETTERS or English numerals.3. Write in CAPITAL LETTERS only within box. Leave blank between words as shown in the example below.4. Attach relevant certificates with application form.5. Attach DD in favour of IGNOU payable at Delhi (to be paid by MOHFW).

A B C D E F G I J K L N O P Q R S T U V X Y Z 0 1 2 3 4 5 6 7 8 9

Signature of Applicant

PHOTOGRAPH

Affix your latestpassport sizephotograph(4 cm x 5 cm)duly attested

by you4. Regional Centre Code:

1. Name of the Programme Applied:

5. Programme Study Centre Code:

7. a. Are your registered with (Ignou)(Please write relevantcode in the box) A1 -

YesB2 - No

If yes, Programme Code:

Enrolment No. :

8. Name of the Candidate:(as in class X/XII mark sheetor equivalent certificiate)

9. Father/Mother/Husband /oName :(Please write S/o or D/o forFather/Mother’s Name andW/o for Husband’s Name)

10. Address for Correspondence : (Please do not give POST-BOX Number. Use Capital Letters and give space between words)

a) House No. : b) Street Name :

c) Locality/Mohalla:

d) Tehsil/District:

e) City : f) Pin Code:

g) State:

11. Contact Details: a) Landline No. Fax, if any: STD No. Phone Number FAX Number

b) e-mail ID: c) Mobile No.:

Date Month Year12. Date of Birth: 13. Nationality A1 - IndianB2 - Others,pl. specify

14. Gender(Pls. write relevantcode in the box)

A1 - MaleB2 - FemaleC3 - Other

15. Category(Pls. write relevantcode in the box)

A1 - GeneralB2 - SCC3 - STD4A - OBC (Creamy)D4B OBC (Non Creamy)

16. Area(Pls. write relevantcode in the box)

A1 - UrbanB2 - RuralC3 - Tribal

17. Marital Status(Pls. write relevantcode in the box)

A1 - SingleB2 - Married

18. Religion(Pls. write relevantcode in the box)

A1 - HinduB2 - MuslimC3 Christian

G7 ParsiH8 JewsI9 Others

D4 SikhE5 JainF6 Buddhist

2. Programme Code:

6. State Code:

A1 EnglishB2 HindiC3 Others

3. Medium of Study(Write code in the box)

20. Social Status(Pls. write relevantcode in the box)

A1 - Ex-ServicemanB2 - War WidowsC3 - Not Applicable

21. Whether Kashmiri Migrant(Pls. write relevantcode in the box)

A1 - YesB2 - No

22. Employment Status (Pls. write relevantcode in the box)A1 - UnemployedB2 - IGNOU regular employeeC3 - EmployedD4 - KVS employee

19. Whether Minority(Pls. write relevantcode in the box)

A1 - YesB2 - No

100

23. Details of Scholarship being received, if anya) Annual Scholarship Amount c) Fimily Income (annual) d) Below Poverty Line

A1 Yese) Jain Inmates

A1 Yes

24. a) Whether a Person with Disability(Pls. write relevantcode in the box)

b) If yes, kindly provide details of disability:(Pls. write relevantcode in the box)

A1 - Speech and Hearing ImpairmentB2 - Locomotor ImpairmentC3 - VVisual ImpairmentD4 - Low Vision

b) Deptt. offering Scholarship:A1 Government

Mental Illness

Mental Retardetion

Leprosy CuredA1 - YesB2 - No

g) Council Registration Number RN RM Name of Nursing Council

h) Whether in Service A1 - YesB2 - No

Place of work ..............................................................................................................................................................................................................................

i) Years of experience after RN/RM

27. Details of fee Remittance:

a) Mode of Payment(Pls. write relevantcode in the box)

A1 - Cash ChallanB2 - Demand Draft

b) Amount : Rs. Please add Rs. 500/- in case of Late fee

c) DD/Challan Number:

e) Bank Name:

28. Declaration:I hereby declare that I have read and understood the conditions of eligibility for the programme for which I seek admission. I fulfill the minimum eligibilitycriteria and I have provided necessary information in this regard. In the event of any information being found incorrect or misleading, my candidature shallbe liable for cancellation by the University at any time and I shall not be entitled to refund of any fee paid by me to the University. Further, I have carefullystudied the rules of the University as printed in the Prospectus and I accept them and shall not raise any dispute in future over the same rules. Iunderstand that the University can amend or change any rules without advance intimation and I will be abiding by them.

Place :Date :

Signature of the Applicant

For office use

ADMITTED NOT ADMITTEDReason for not admitting Signature with date

25. Educational Qualifications:

A1 - 12th

B2 - 10th

a) Whether 10th or 12th pass b) Main Subjects1. ____________________2. ____________________3. ____________________

c) Year of Passing f) Board Code/Universityd) Division e) %age of Marks

a) Qualification b) Main Subjects1. ____________________2. ____________________3. ____________________

c) Year of Passing f) Board Code/Universityd) Division e) %age of Marks

26. Relevant Qualifications (which make you eligible for application to the programme) GNM/B.Sc.N

4. ____________________ 01,02,03 or 04 for pass

01,02,03 or 04 for pass

A1 - GNMB2 - BScNC3-Any other

INSTRUCTIONS FOR CANDIDATES1. Please send your Application Form by Registered/Speed Post to School of Health Sciences, IGNOU.2. Last date for receipt of filled in application form is as per advertisement.3. Please retain photo copy of the filled application form for future reference.4. For Detailed instructions please refer Student Handbook & Porspectus.5. Self attested Photocopy of all the relevant certificates of DOB, Category, Employment, Educational Qualification, relevant

Qualification making you eligible for application to programme, Council Registration and Demand Draft must be send along withthis application form.

6. Original Certificates will be verified.7. Fill up the column of E-Mail ID and correct mobile no., otherwise candidate will be responsible for non receipt of

communication.