Affix recent Photograph

attested bythe Gazetted

officer/ Principal of the
Application No:210 College where last studied
GOVERNMENT OF ANDHRA PRADESH
Date:25.08.2023 APPLICATION FORM FOR ADMISSION INTO GENERAL NURSING AND MIDWIFERY COURSE
IN THE GOVERNMENT/PRIVATE SCHOOLS FOR NURSING – ANDHRA PRADESH FOR THE YEAR 2023-2024

1.Name in Full: Chelluboina Likhitha

(as per SSC Certificate)
2.Full Name of the Father / Guardian: Ramudu
3.Postal address: 3-55,NERALA BALASA,BHEEMUNIPATNAM
Pin Code: 531163 Aadhar Number: 908492822393
4.Date of Birth: 01.09.2005 5.Age :18Y 6.Gender: FEMALE
7.Nationality: INDIAN 8.Religion: HINDU
9.Native District: VISAKHAPATNAM 10.State: ANDHRA PRADESH
11.Mother Tongue: Telugu 12.Seat: Government Free Seat
13.Name of Institution: School of Nursing K.G.H, Visakhapatnam
14.Educational Qualification: BOARD OF INTERMEDIATE EDUCATIO 15.Hall Ticket No: 2302241283
16.First appearance of Qualifying Exam: APRIL 17.Year: 2022
18.Completed Qualifying Exam: JUNE 19.Year: 2023
20.Marks obtained in Intermediate or equivalent Exam Total Marks(GPA) :491/ Marks Secured(GPA): 491
20(A)
Sl.No Subject Max Marks/ Obtained Result
Marks (GPA)
1 ENGLISH 44/35 Passed
2 TELUGU 67/74 Passed
3 BOTANY 22/21 Passed
4 ZOOLOGY 21/21 Passed
5 PHYSICS 21/21 -
6 CHEMISTRY 28/23 -
7 NIL 0/0 -
8 NIL 0/0 -
9 NIL 0/0 -
10 NIL 0/0 -
20(B).Particulars of study – details for the Four / Seven consecutive academic years ending with the month and year of qualifying
Exam.
Academic Year Class Name of the School / Place Village/ Town/ Mandal Dist.
in Which Resided
2016-2017 VI class CBM AIDED HIGH SCHOOL BHEEMUNIPATNAM
2017-2018 VII class CBM AIDED HIGH SCHOOL BHEEMUNIPATNAM
2018-2019 VIII class CBM AIDED HIGH SCHOOL BHEEMUNIPATNAM
2019-2020 IX class CBM AIDED HIGH SCHOOL BHEEMUNIPATNAM
2020-2021 X Class CBM AIDED HIGH SCHOOL BHEEMUNIPATNAM
2021-2022 Inter Mediate GOVT. JUNIOR COLLEGE BHEEMUNIPATNAM
Junior
2022-2023 Inter Mediate GOVT. JUNIOR COLLEGE BHEEMUNIPATNAM
Senior

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 Application No:210

21.Social Status: BC-A 22.Local Area: Visakhapatnam , Zone 1

23.Challan No: 71255493162023 24.Amount Rs: 500 25.Challan Date: 25.08.2023
26.Bank: 70120777302023 27.Place: AP
28.Two Persons/ relatives for referance.
a)1st Ref Name: Y GOVINDA RAO Occupation: INDIAN NAVY
Address: 15-18-5,NERALAVALASA COLONY, BHEEMILI
b)2nd Ref Name: CH SAI KUMAR Occupation: MECHANIC
Address: 3-55,NERALAVALASA,BHEEMILI
DECLARATION
I hereby solemnly and sincerely affirm that the statement made and information furnished by me in the application form
and also in all the enclosures thereto submitted by me are true and correct. I have not kept any information secret should it
however be found that any information furnished therein is fraudulent, incorrect or untrue in material particulars, I realize that my
selection or admission to the course is liable to be cancelled and I am liable to criminal prosecution. Further I also agree to forego
my seat in the school of Nursing unconditionally.

Signature of the applicant

________________________________________________________________________________________________________
I have fully read the information furnished by my daughter / ward and affirm that it is true and if it is proved that the
information was fraudulent, I am liable to prosecution.

Signature of Father / Guardian

(If father is not alive)
Note:- No application will be entertained unless the declaration is signed by candidate and parent / guardian (if father is not alive).
________________________________________________________________________________________________________
Documents to be submitted along with the application form
1. Certificate of social status in case of candidates belonging to SC/ ST / BC in the form prescribed vide Annexure – I of
this notification.
2. 7years residence certificate by the candidates claiming eligibility as a local candidate by the virtue of residence as in
Annexure- II of this notification and 10 years residence certificate of parents of Non- local candidate.
3.Challan paid towards Registration fee (original) for Rs. 500/-
4.Attested copy of S.S.C. or any equivalent examination showing identity of the date of birth of the candidate.
5.Attested copy of the Intermediate certificate showing statement of marks obtained in the qualifying examination.
6.Attested copy of the Study / Bonafide Certificate from 6th to Intermediate Senior.
7.Two attested conduct certificates, one from the Head of the Institution in which the candidates studied and the other from a
respectable officer of the State Government or any other respectable person.
8.Attested copy of the transfer certificate from the institution in which the candidate last studied.
9.Two recent passport size photograph duly attested by a Gazetted officer.
10.The following certificates are required in respect of SC/ ST/ BC candidates in addition of the above:
a)Scholarship certificate if received scholarship (Attested Copy)
b)Service record and SSLC certificate of parent, if in service for verification of Social Status (Attested Copy)
c)Service certificate and SSLC certificate of nearest relatives , if parent is not in service for verification of social Status.
11.Two self addressed envelopes 11 cms X 27 cms, size affixing stamps worth Rs.30/- each.

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