Staff Nurse Self Registration | Hari Om Mother Father Home Healthcare

Personal Information

Title *

First Name *

Last Name *

Gender *

Date of Birth *

Marital Status *

Blood Group with RH Factor

Differently abled *

Father Name *

Religion

Contact Information

Mobile Number *

Alternative Mobile Number

Emergency Contact Number

Email ID

Address - Line 1 *

Address - Line 2

City

State

PIN Code

Education

Primary Qualification *

You can add multiple qualifications (GNM, BSc, MSc, Diploma, 12th etc).

Qualification

Name of School / University

Course Type

Passout Year

Percentage

Registered as Nurse in which State

Registration valid till (Year)

Upload Marksheets (multiple files)

Upload Certificates (multiple files)

Aadhar Card Upload (multiple files)

Passport Size Photo Upload

Experience

Total Years of Experience

You can add multiple past organisations.

Name of Organisation

Designation

Joining Date

Still working here

Last Working Date

Current / Last CTC

Bank Details

Bank Name

Name on Passbook

Account Number

Re-enter Account Number

IFSC Code

Mobile Number (linked with bank)

I confirm that the information provided above is true and correct to the best of my knowledge. I understand that providing false information may lead to rejection of my registration or termination of employment.