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 [email protected] or contacting your Vostek consultant.
