REGISTRATION FORM

U.P. NURSES & MIDWIVES COUNCIL

5, Sarvpalli, Mall Avenue Road, Lucknow
Office :- 0522-2235965, 2238846, Fax :- 2236600, E-mail : upnursescouncil@upsmfac.org

Application Form for Registration with U.P. Nurses & Midwives Council

ORIGINAL DUPLICATE ADDITIONAL

Name of the Course :

ANM/H.W.(F) GNM B.Sc. Nursing M.Sc. Nursing P.B.B.Sc.Nursing Post Basic Diploma Course

Receipt # Date

Reg. No. :
Neatly paste your latest
Candidate Signature in Upper Box colour photograph in
Date of Birth : this box duly
attested by principal
E-mail of training centre

Seal & Sign. of Principal/ attesting authority

Aadhaar No. Mob. No.

First Name

Sur Name

Father's Name

Mother's Name

Permanent Address

District Pin

State

Nationality Gender (M/F) :

Training Centre Code :

(I.N.C.)
Name of Training Centre :

Name of Examining
Body / University

Month & Year of Joining Month & Year of Passing

Month Year Month Year

Name of the Council
(if Outside Candidate)

PRESENCE OF CANDIDATE IS MUST FOR APPLYING

Candidate should bring originals for verification. No need to submit. INSTRUCTIONS OVER LEAF
INSTRUCTION
1- Use Black Ball pen for filling up the form.
2- Stick Colored passport size photograph, do not staple or pin.
3- Fill the form in English capital letters & number in English numeric character.
4- Do not use abbreviation as SMT, LATE, KM, SHRI, etc.
5- Since it is an ICR form, please do not fold.
6- Photograph & Signature should be duly attested by Principal of Training Centre.

ENCLOSURES
Nurses of the State (U.P.) (Only for B. Sc. Nurses)
1- Date of Birth Certificate (photocopy of High School certificate and Intermediate mark sheet).
2- Photocopy of all year mark sheets.
3- Provisional Certificate from University.
4- Course completion Certificate from the Institution.
5- Affix photograph & signature in the box mentioned in the form and get it duly attested by
Principal of the College.

Nurses of the Other State (G.N.M./B. Sc./A.N.M/ H. W.(F) Nurses)

1- Photocopy of Registration Certificate from parent council.
2- Photocopy of Employer I.D. Proof from Institution.
3- Date of Birth Certificate, photocopy of High School certificate and Intermediate mark sheet.
4- Photocopy of all year mark sheets.
5- Provisional Certificate from University.
6- Affix photograph & signature in the box mentioned in the form and get it duly attested by Principal
of the College.

For Duplicate Registration

1- Copy of F.I.R.
2- Publication in Newspaper.
3- Affidavit.
4- Signature & photograph should be attested by Principal/ attesting authority.

For registration of Additional Qualification

(Only for Post Basic B.Sc Nursing / M.Sc. Nursing / Post Basic Diploma Courses)
1- Photocopy of U.G. Degree Registration Certificate of U.P. Nurses & Midwives Council.
2- Photocopy P.G. Degree Provisional Certificate from the University/ Board.
3- Course completion Certificate from the Institution.
4- Photocopy of all year mark sheets.
5- Affix photograph & signature in the box mentioned in the form and get it duly attested by Principal
of the College.
6- Details of Fee
Sr. No. Registration Fee
1 General Nurses & Midwife Registration Rs. 1500/-
2 Health Worker (Female) Registration Rs. 1500/-
3 General Nurse Registration Rs. 1500/-
4 Auxliary Nurse - Midwife Registration Rs. 1500/-
5 Midwifery Registration Rs. 1500/-
6 B.Sc. Nursing / M.Sc. (Nursing) / Post Basic B.Sc. Nursing Registration Rs. 2500/-
7 Post Basic Diploma in Psychiatric / Mental Health Nursing Registration Rs. 2500/-
8 Duplicate/Correction Copy of Registration Certificate Rs. 1000/-
9 English Translation of Old Hindi Registration Rs. 500/-
10 Name Change Rs. 500/-
11 Foreign Confirmation Rs. 5000/-
12 Verification (Local) Rs. 500/-
13 Good Standing Rs. 500/-
14 ID Card (Smart Card) Rs. 250/-
15 No Objection Certificate Fee Rs. 500/-