[Insert KNMC Logo Here]
Kerala Nurses and Midwives Council
[Insert KNMC Address]
Application for Good Standing Certificate
Personal Information:
1. Name: [Your Full Name]
2. Registration Number: [Your KNMC Registration Number]
3. Date of Birth: [DD/MM/YYYY]
4. Gender: [Male/Female/Other]
5. Address: [Your Complete Postal Address with PIN Code]
6. Phone Number: [Your Contact Number]
7. Email Address: [Your Email Address]
Educational Qualifications:
8. Diploma in General Nursing (G.N.M.):
- Institution: [Name of Institution]
- Year of Passing: [YYYY]
9. Post Basic B.Sc. Nursing:
- Institution: [Name of Institution]
- Year of Passing: [YYYY]
10. Other Qualifications (if any): [List Any Other Relevant Qualifications]
Professional Experience:
11. Current Designation: [Your Current Designation]
12. Employer: [Name of Employer]
13. Address of Employer: [Complete Postal Address of Employer]
14. Years of Experience: [Total Number of Years of Professional Experience]
15. Career Summary: [Provide a brief summary of your professional career, mentioning key achievements, if any]
Reason for Requesting Good Standing Certificate:
16. Purpose: [Indicate the purpose for which you require the Good Standing Certificate, e.g., Continuing Education, Overseas Employment, etc.]
17. Country (if applicable): [Specify the country where you intend to use the certificate, if it's for overseas purposes]
Declaration:
I hereby declare that the information provided in this application is true and correct to the best of my knowledge. I understand that any false or misleading information may result in the rejection of my application.
Signature: __________________________________
Date: [DD/MM/YYYY]
Instructions:
1. Please submit this completed application form, along with the prescribed fee, to the Kerala Nurses and Midwives Council office.
2. The fee must be paid through the designated payment method as per the current guidelines of the KNMC.
3. Kindly attach copies of relevant documents supporting your qualifications and experience, such as diplomas, certificates, and experience letters.
4. The KNMC may take a few working days to process and issue the Good Standing Certificate.
For Office Use Only:
Application Received: __________________
Certificate Issued Date: __________________
Reference Number: ____________________
