Nurse Registration Form RecentPhotoHere

5. ADDITIONAL INFORMATION

Do you have any significant disabilities or health problems?

If you have previously been to Australia for study or work, please describe:

If you have any direct relatives in Australia, please describe:

What Australian state or city are you most interested in living, if any?

What is your professional interest in Australia?

Long term work (up to 4 years): Permanent Skilled Migration:

Any other comments:

Family Name:

Given Names:

Date of Birth: Day Month Year

Male: Female:

Passport Number:

Languages Spoken:

Nationality:

Address in Home Country:

Telephone: Fax:

Email:

Address in Australia (if applicable):

Telephone in Australia (if applicable):

1. PERSONAL DETAILS

Name of College or University:

2. NURSING EDUCATION

What is your highest level of Nursing Education?

Degree: Diploma:

Date Completed: Day Month Year

IETLS:

Date Test Taken: Day Month Year

Results: R: W: L: S:

3. ENGLISH LANGUAGE

OET:

Other? Describe:

Other Results

4. CURRENT LICENCES & CERTIFICATES

Licence # 1: Licence Number:

Country:

Year Obtained: Expires:

Licence # 2: Licence Number:

Country:

Year Obtained: Expires:

6. AREAS OF EXPERIENCE

Emergency Department: Number of Months:

Intensive / Critical Care: Number of Months:

Medical / Surgical: Number of Months:

Neonatal / Neonatal ICU: Number of Months:

Pediatric / Pediatric ICU: Number of Months:

Perinatal: Number of Months:

Perioperative: Number of Months:

Psychiatric Nursing: Number of Months:

Surgical Technician: Number of Months:

Telemetry / Immediate Care: Number of Months:

Aged & Palliative Care: Number of Months:

Any other professional specializations?

How did you hear about Vostek?

If these details change, you should notify Vostek by sending an email to info@vostek.net.au or contacting your Vostek consultant.