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Application for Registration:

* Fields are mandatory

PERSONAL INFORMATION:

Name (in full)*


Last name/family name	First name/Given name	Middle name(s)

Former Name(s)

Maiden/Former or Secular name

Preferred Name

Present Address


Number	Street	Town / City

State/Province/Country	Postal Code	Phone No. & Area Code

Date of Birth*

Day Month Year

Sex*

Male Female

Marital Status*

Single Married Widow Divorced other

Number of Children
(under 22 years of age)

Native or first language

Place of Birth

Email*

Have you ever been convicted
of a criminal offence or do you
have any outstanding charges

Yes No

Non nursing education :

Non nursing education	Language of instruction	Country	Date of entry	Completion date	Certificate
Primary
Secondary (high school)
Post-Secondary

NURSING EDUCATION - Enter actual name of nursing school/program :

Name and Address of Each Nursing Program Attended	Language of instruction	Date Entered YR/MO	Date Completed YR/MO	Received/Will Receive (Specify i.e., RN, RPN)
				Diploma/Certificate

				Degree

				Diploma/Certificate

				Degree

				Diploma/Certificate

				Degree

Areas Included in Nursing Education Program :

	Medical	Surgical	Maternity	Children	Psychiatric	Community	Gerontology
Theory / Classroom
Practical / Clinical Experience

REGISTRATION STATUS AND NURSING EXPERIENCE: Complete all questions (If not applicable write N/A)

Where did you first obtain
registration?


State / Province / Country	Date

What is your legal title in the
province/state/country in which
you first obtained registration?

In what other provinces /
states / countries have you
registered?

Where are you Nursing Today?

Your Specialty?

Have you ever written the
Canadian registration
examination?

Yes No

If yes, record dates and
locations of all previous
writings

Is there any reason that you
may not be fit to engage in the
practice of nursing?

Yes No

If yes, explain why?

Have you applied to any
Provincal Canadian Nursing
Associations?

Yes No

If yes, explain

Have you ever been denied
registration?

Yes No

If yes, explain why?

Have you been disciplined by a
professional regulatory body?

Yes No

If yes, explain why?

Has your registration ever been
revoked or suspended or had
conditions attached?

Yes No

If yes, explain why?

Have you been registered with
any other profession e.g.,
social work, RPN, LPN?

Yes No

If yes, explain why?

Record the total number of hours for each year you actually worked in nursing (graduate or registered
nurse) from January to December in the past five years. Do not include hours as a student nurse. Your
application cannot be processed without this information.

2008 hours (current year, to date of application)	2005 hours (three year previous)
2007 hours (one year previous)	2004 hours (four year previous)
2006 hours (two year previous)	2003 hours (five year previous)

What is your total number of
formal years of education?

What is the highest level of
education your Spouse has
obtained?

What is the total number of
formal years of education for
your spouse?

Do you have family in Canada?

Yes No

If yes, please specify
relationship & city

How did you hear about us?

Newspaper Friend Other

If other, please specify

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