Application Form

Type: General registration (graduated or trained overseas) Profession: Nursing and Midwifery

AGOS-40

*AGOS-401*

Section 77 of the Health Practitioner Regulation National Law Act (the National Law)

This form is to be used by overseas graduates or overseas trained applicants applying for general registration as a Registered Nurse, Enrolled Nurse or Midwife in Australia. This application must be completed by the applicant and not by a third party. Additional registration types can be found on the Nursing and Midwifery Board of Australia (the Board) website at www.nursingmidwiferyboard.gov.au Applicants with registration as a nurse or midwife in New Zealand are subject to certain entitlements under the Trans Tasman Mutual Recognition Act 1997 (Cwlth) and should apply for registration using form ATMR-40, which can be found at www.nursingmidwiferyboard.gov.au/forms.aspx Do not submit this application unless it is complete and all supporting documentation has been provided. All supporting documentation must: be certified in accordance with AHPRA guidelines be in English. If original documents are not in English, you must provide a certified copy of the original document and translation in accordance with the AHPRA guidelines DO NOT send original documents. The AHPRA guidelines for certifying documents can be found at www.ahpra.gov.au/certify.aspx It is important that you refer to the Boards registration standards, codes and guidelines when completing the form. These documents can be found at www.nursingmidwiferyboard.gov.au PRIVACY AND CONFIDENTIALITY The information collected in this form is authorised or required under the National Law for the purposes of determining an applicants eligibility for registration. Information supplied on this form may be provided to other persons and agencies as specified by the National Law. The Board and the Australian Health Practitioner Regulation Agency (AHPRA) are committed to ensuring the privacy and confidentiality of personal information held and will adhere to the National Privacy Principles under the Privacy Act 1988 (Cwlth) when collecting, using, disclosing, securing and providing access to private information. AHPRAs Privacy Policy explains how your personal information will be stored, handled and used. This document can be accessed at www.ahpra.gov.au/privacy.aspx OFFICE USE ONLY
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COMPLETING YOUR APPLICATION Read all instructions Print clearly in BLOCK LETTERS using a black or blue pen Place X in ALL applicable boxes:

SECTION A: Application type

1. What type of registration are you applying for?
Please mark all options that are applicable to your application

General registration
Registered Nurse Enrolled Nurse Midwife

SECTION B: Personal details and identification

The information items in this section of the application that are marked with an asterisk (*) will appear on the public register. 2. What is your name?
* Mr Mrs Miss Ms Dr Other * Family (legal) name

* First given name

* Middle given name(s)

Previous names and other names known by

Preferred name

* Sex

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*AGOS-402*
3. What are your birth details?
Date of birth

7. What are your contact details?

During business hours

DD / MM / YYYY
Country of birth

After hours

(
Place/City of birth Mobile

State of birth (if within Australia) VIC WA NSW NT QLD TAS SA ACT

Email

* Languages spoken other than English (optional)

8. Would you like to receive your renewal communications electronically?

Some communication will always be sent by post

4. What is your residential address?

No. Suburb State/ Territory Postcode Street

Yes No

Send my renewal notices to the email address nominated above Go to the next question

9. Please read this before answering the following questions about identification documents:
You must provide at least one document from each of the following categories: Category A: Commencement of identity in Australia Category B: Link between the identity and person by means of photo and signature Category C: Evidence of identity operating in community, and Category D: Evidence of identitys residential address, if your category B or C document does not provide this evidence. You will find: etails of the documents which are applicable in each of d these categories; and he requirements for persons who are applying from t overseas, or have recently arrived in Australia at www.ahpra.gov.au/identity.aspx The AHPRA guidelines for certifying documents can be found at www.ahpra.gov.au/certify.aspx AHPRA has the right to request presentation of the original documents.

5. Is your residential address the same as your principal place of practice in Australia? Yes No
Go to the next question Provide your principal place of practice address below If you do not yet know this address, please indicate the Australian State or Territory of your principle place of practice
Site name No. *Suburb *State/ Territory Postcode Street

6. Where do you want postal correspondence delivered?

Residential address Principal place of practice Please send correspondence to the approved agent, listed in Section G of this form Other (Provide your postal correspondence address below)
No. Street Suburb State/ Territory Postcode PO Box.

Does your proof of identity include your passport? Yes

Provide details below

Passport type (e.g. private/government) Country of issue Passport number

You must attach a certified copy of your passport.

No
Effective from: 19 September 2011

Go to the next question

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10. Does your proof of identity include an Australian Licence? Yes
Drivers
State of issue Licence number

Provide details below Firearm

You must attach a certified copy of all your academic qualification(s) e.g. academic transcript mentioned within this form. If original documents are not in English, you must provide a certified copy of the original document and translation in accordance with the AHPRAs guidelines.

You must attach a certified copy of your licence.

Additional qualification and examinations/assessments

Title of qualification

No

Go to the next question Name of institution (University/College/Examining Body)

SECTION C: Qualification for the profession

In accordance with section 52 of the National Law, to be eligible for general registration you must be qualified for general registration in the health profession. Section 53 of the National Law states that to be qualified you must either: a. hold an approved qualification for the health profession b. hold a qualification that the Board considers to be substantially equivalent, or based on similar competencies, to an approved qualification c. hold a qualification, not referred to in (a) or (b), relevant to the health profession and have successfully completed an examination or other assessment required by the Board for the purpose of general registration in the health profession d. hold a qualification, not referred to in (a) or (b), that under the National Law, or a corresponding prior Act, qualified you for general registration in the health profession and you were previously registered on the basis of holding that qualification. The Boards website contains information on approved qualifications accepted under section (a) above and examinations or assessments accepted under section (c) above. 11. What are the details of your qualifications and examinations/assessments?

Country

Start date

Completion date

MM / YYYY 3

MM / YYYY

Additional qualification and examinations/assessments

Title of qualification

Name of institution (University/College/Examining Body)

Country

Start date

Completion date

MM / YYYY

MM / YYYY

Attach a separate sheet if your qualifications do not fit within the spaces provided.

Most recent qualification and examinations/assessments

Title of qualification

Name of institution (University/College/Examining Body)

Country

Start date

Completion date

MM / YYYY

MM / YYYY

You must attach a certified copy of all your academic qualifications and examinations/assessments mentioned within this form.

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*AGOS-404*
SECTION D: Registration history
The Board requires a Certificate of Registration Status or Certificate of Good Standing from every jurisdiction outside of Australia in which you are currently, or have previously been registered as a health practitioner during the last five years.
You must arrange for original Certificates to be forwarded directly from the licensing or registration authority to the Nursing and Midwifery Board of Australia

SECTION E: Work history

13. What is your full practice history?
You must attach to your application a Statement of Service from your employer/s over the last 5 years, and a Curriculum Vitae. The Statement of Service is required to: Be on the employers letterhead Provide dates of employment Describe the role in which you were employed, and whether if was full-time/part-time hours Be signed by a manager (e.g. Director of Nursing, Unit Manager or HR Manager) You must attach to your application a Curriculum Vitae that describes your full practice history and any clinical or procedural skills undertaken. The information contained in your Curriculum Vitae will further inform the Board in relation to your recency of practice and registration history. Your Curriculum Vitae must: Detail any gaps in your practice history of more than three months from the date you obtained your qualification Include evidence of continuing professional development as per the Boards Continuing professional registration standard, found at http://www.nursingmidwiferyboard.gov.au/ Registration-Standards.aspx Be in chronological order

12. What is your health practitioner registration history?

Your registration history must be recorded in order from your first to your most recent registration.

Initial registration

State / Territory / Country

Category of registration

Profession

Period of registration

DD / MM / YYYY

to

DD / MM / YYYY

Be signed and dated with a statement This Curriculum Vitae is true and correct as at (insert date) Be the original signed Curriculum Vitae (no faxes or scanned copies will be accepted). It must also contain all the elements defined in AHPRAs Standard Format for Curriculum Vitae which can be found at www.ahpra.gov.au/cv.aspx

Additional registration

State / Territory / Country

Category of registration

Profession

Period of registration

DD / MM / YYYY

to

DD / MM / YYYY

Attach a separate sheet if your registration history does not fit within the spaces provided.

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*AGOS-405*
SECTION F: Suitability statements
Registration is dependent on suitability as defined in the National Law and the requirements set out in the Boards registration standards on the website www.nursingmidwifery.gov.au. Information required by the Board to assess your suitability for registration is detailed in the following questions. It is recommended that you provide as much information as possible to enable the Board to reach a timely and informed decision.

17. Did you graduate more than 12 months ago? Yes No

Go to the next question Go to question 19

18. Which of the following have you completed? Practised the profession while registered within the past five years for a period equivalent to a minimum of three months full time
Go to the next question

14. Please read this before answering the following question about criminal history:
Criminal history includes the following, whether in Australia or overseas, at any time: Every conviction of a person for an offence Every plea of guilty or finding of guilt by a court of the person for an offence, whether or not a conviction is recorded for the offence Every charge made against the person for an offence. Under the National Law, spent convictions legislation does not apply to criminal history disclosure requirements. Therefore, a complete criminal history will be supplied to the Board irrespective of the time that has lapsed since the charge was laid or the finding of guilt was made. The Board will decide whether a health practitioners criminal history is relevant to the practice of the profession. For further information on the factors the Board will consider in making this decision, see the Criminal history registration standard, which can be found at www.nursingmidwiferyboard.gov.au

Successfully completed a program or course approved by the Board within the last five years for the purpose of re-entry to practice
Go to the next question

Successfully completed a supervised practice experience approved by the Board within the last five years
Go to the next question

Successfully completed a supervised practice experience approved by the Board within the last five years
Go to the next question Practice means any role, whether remunerated or not, in which the individual uses their skills and knowledge as a nurse or midwife. In accordance with the Recency of practice registration standard, practice is not restricted to the provision of direct clinical care. It also includes working in a direct non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles and any other roles that impact on safe, effective delivery of services in the profession and/or use of professional skills. Practice hours may be recognised if: you have practised your profession for a minimum period equivalent to three months full time, within the past five years the applicant held valid registration with a nursing or midwifery regulatory authority in the jurisdiction (either Australia or overseas) when the hours were worked; or the role involved the application of nursing and/or midwifery knowledge and skills; or the time was spent undertaking postgraduate education leading to an award or qualification that is relevant to the practice of nursing and/or midwifery. For further information on requirements see the Boards Recency of practice registration standard which can be found at www.nursingmidwiferyboard.gov.au

Do you have any criminal history in Australia? Yes

Provide a separate sheet with your criminal history and explanation of circumstances in Australia. Go to the next question

No

15. Do you have any criminal history in another country? Yes

Provide a separate sheet with your criminal history and explanation of circumstances in another country. Go to the next question

No

16. Do you commit to only practice the profession if you have appropriate professional indemnity insurance arrangements in place?
Nurses and midwives must not practise their professions unless they are covered in the conduct of their practice by appropriate professional indemnity insurance arrangements. Nurses and midwives can meet this requirement through employers insurance, private insurance cover or insurance gained through membership of a professional or industrial organisation. It is the nurse or midwifes responsibility to understand the nature of the cover supplied under these three options. Exemption from professional indemnity insurance requirements apply to midwives practising private midwifery. For further information on requirements see the Boards Professional indemnity insurance registration standard which can be found at www.nursingmidwiferyboard.gov.au

19. Do you have an impairment that detrimentally affects or is likely to detrimentally affect your capacity to practise the profession?
Impairment means a physical or mental impairment, disability, condition, or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect your capacity to practise the profession.

Yes

You must attach details of any impairments and how they are managed to this application. Go to the next question

Yes No
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Go to the next question

No

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20. Is your registration in the profession, in Australia or overseas, currently suspended or cancelled? Yes
You must attach details of any registration suspension or cancellation to this application. Go to the next question

No

21. Have you previously had your registration cancelled, refused or suspended in Australia or overseas? Yes
You must attach details of any cancellation, refusal or suspension to this application. Go to the next question

25. Do you hold, or have you previously held, registration in Australia as an enrolled nurse, a registered nurse or a registered midwife with either: the Nursing and Midwifery Board of Australia (NMBA) (from 1 July 2010); or a previous Australian state or territory nursing or midwifery Board (prior to 1 July 2010) No Go to the next question Yes Please select board(s)
NMBA Australian state/territory board Both Provide further information on your registration below and then Go to Section G: Obligations of registered health practitioners

Enrolled Nurse
Currently hold registration: Registration number: YES NO

No

NMBA information:

22. Has your registration ever been subject to conditions, undertakings or limitations in Australia or overseas? Yes
You must attach details of any conditions, undertakings or limitations. Go to the next question

N M W
Australian state or territory board information: State/territory of registration

No

Initial date of registration Lapse date of registration

23. Are you disqualified, under the National Law or a corresponding prior Act, from applying for registration, or being registered, in the profession? Yes
You must attach details of any disqualifications to this application. Go to the next question

MM / YYYY MM / YYYY

Registered Nurse
Currently hold registration: Registration number: YES NO

NMBA information:

No

N M W
Australian state or territory board information: State/territory of registration Initial date of registration Lapse date of registration

24. Have you been or are you the subject of conduct, performance or health proceedings whilst registered under the National Law, a corresponding prior Act or the law of another jurisdiction in Australia or overseas, where those proceedings were not finalised? Yes
You must attach details of any conduct performance or health proceedings to this application. Go to the next question

MM / YYYY MM / YYYY

Registered Midwife
Currently hold registration: Registration number: YES NO

NMBA information:

No

N M W
Australian state or territory board information: State/territory of registration Initial date of registration Lapse date of registration

MM / YYYY MM / YYYY

If you no longer hold registration as a nurse or midwife in Australia, to be considered as continuing to meet the English language skills registration standard you must attach evidence that you have maintained continuous professional practice in an English speaking environment and/or residence in one of the recognised countries listed in Question 26.
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*AGOS-407*
26. Please read this before answering the following questions about English language skills:
For Registered nurses and midwives: The completion of five (5) years full time equivalent education, taught and assessed in English, means five (5) years full time equivalent of either: (i) tertiary and secondary; or (ii) tertiary and vocational; or (iii) combined tertiary, secondary and vocational education taught and assessed in English in any of the recognised countries listed below. These five (5) years must include evidence of a minimum of two (2) years full time equivalent pre-registration program of study approved by the recognised nursing and/or midwifery body in any of the recognised countries. For Enrolled Nurses: The completion of five (5) years full time equivalent education, taught and assessed in English, means five years full time equivalent of either: (i) vocational and secondary; or (ii) vocational and tertiary; or (iii) combined vocational, secondary and tertiary education taught and assessed in English in any of the recognised countries listed below. These five (5) years must include evidence of a minimum of one year full time equivalent pre-registration program of study approved by the recognised nursing and/or midwifery body in any of the recognised countries.

Have you completed 5 years full-time equivalent education as outlined above, taught and assessed in English, in one or more of the following recognised countries? No Go to the next question Yes Provide the following details regarding your education in English and then go to Section G: Obligations of registered health practitioners.
Please mark all applicable countries

Australia New Zealand

Program name If program incomplete, include subjects completed in the program

South Africa United Sates of America

Education institution Name and address

Canada Republic of Ireland

United Kingdom
Student status (F/T) (P/T)

Highest secondary Time frame level; tertiary and/or Month and year vocational qualification (e.g. Secondary - Yr 12, Commenced Completed (MM/YYYY) (MM/YYYY) Tertiary - degree)

Recognised country (See above)

Academic transcript Attached

For each program, you must provide a certified copy of your Academic Transcript (AT) detailing all subjects completed and, if program is complete, a Certificate of Attainment (CoA). Please attach a separate sheet with any additional details that do not fit within the space provided above.

27. Which of the English language examinations listed below have you successfully completed?
International English Language Test System (IELTS) - academic module, with a minimum score of 7 in each of the four components of listening, reading, writing and speaking Occupational English Test (OET), with an overall pass and with grades of A or B only in each of the four components of listening, reading, writing and speaking

28. Have your results from the above mentioned English language examinations been obtained within two years prior to applying for registration?
Pass result must be obtained in one sitting.

Yes No

Go to the next question You must attach evidence that you: have actively maintained continuous practice and/or employment as a registered nurse, enrolled nurse or midwife using English as the primary language of practice in one of the recognised countries, listed in Question 26; and/or have been continuously enrolled in a program of study taught and assessed in English and approved by the recognised nursing and/ or midwifery regulatory body in any of the recognised countries listed in Question 26.

Date the exam was completed:

DD / MM / YYYY

You must arrange for the testing authority to provide evidence of your successful completion of the Board approved English language test directly to the relevant State or Territory office of AHPRA.

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*AGOS-408*

SECTION G: Agent authorisation

29. I consent to this application being discussed with and relevant correspondence sent to: Migration agent Significant other (Please fill out details below)
Name

the practitioners registration, under the law of another country that provides for the registration of health practitioners, is suspended or cancelled or made subject to a condition or another restriction.

SECTION I: Consent
30. PLEASE READ AND MAKE SURE YOU UNDERSTAND THESE STATEMENTS BEFORE SIGNING:
I consent:

Address
No. Suburb State/ Territory Postcode Street

to the Board and AHPRA making enquiries of, and exchanging information with, the authorities of any Australian state or territory, or other country, regarding my practice as a health practitioner or otherwise regarding matters relevant to this application. I authorise: the Board to obtain my criminal history in Australia and overseas. I understand: that a complete criminal history, including resolved and unresolved charges, spent convictions and findings of guilt for which no conviction was recorded, will be released to the Board that information will be extracted from this form and used for the purpose of criminal history checking. This information may be used by Australian police services for law enforcement purposes including the investigation of any outstanding criminal offences. I acknowledge: that the Board may validate documents provided in support of this application as evidence of my identity that failure to complete all relevant sections of this application and enclose all supporting documentation may result in this application not being accepted. I undertake: to comply with all relevant legislation, the Board Registration Standards, Codes and Guidelines.

During business hours

( (
Mobile

) )

After hours

SECTION H: Obligations of registered health practitioners

Registered health practitioners must inform the Board of a change in their status in relation to the following matters within 7 days after becoming aware of that change: the practitioner is charged with an offence punishable by 12 months imprisonment or more the practitioner is convicted of or the subject of a finding of guilt for an offence punishable by imprisonment appropriate professional indemnity insurance arrangements are no longer in place in relation to the practitioners practice of the profession the practitioners right to practise at a hospital or another facility at which health services are provided is withdrawn or restricted because of the practitioners conduct, professional performance or health the practitioners billing privileges are withdrawn or restricted under the Medicare Australia Act 1973 (Cwlth) because of the practitioners conduct, professional performance or health the practitioner has a restriction placed on their right to prescribe or supply pharmaceutical benefits under the National Health Act 1953 the practitioners authority under law of a state or territory to administer, obtain, possess, prescribe, sell, supply or use a scheduled medicine or class of scheduled medicines is cancelled or restricted a complaint is made about the practitioner to a Commonwealth, state or territory entity having functions relating to professional services provided by health practitioners or the regulation of health practitioners, including, but are not limited to: overseas regulatory authorities Commonwealth departments that administer Medicare Australia; the provision of pharmaceutical, sickness and hospital scheme; payments by way of medical benefits and payments for hospital services; and immigration state and territory bodies responsible for health complaints, workers compensation and traffic accident investigation

I declare: that the above statements, and the documents provided in support of this application, are true and correct that I am the person named in the attached documents. I make: this declaration in the knowledge that a false statement is grounds for the Board to refuse registration. Signature of applicant/registrant Date

SIGN HERE
Printed name of applicant/registrant

DD / MM / YYYY

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*AGOS-409*
SECTION J: Payment
31. How are you paying your registration fee?
Payments by cheque, money order or bank draft must be in Australian currency, drawn on an Australian bank.

You are required to pay both an application and a registration fee.

Mark one box only Visa or MasterCard (credit or debit card)

Fill out the credit / debit card payment slip below

Refund rules The application and assessment fees are non-refundable. The registration fee will be refunded if the application is not approved. Fees The fees applicable are outlined below. Registrants with a principal place of practice in New South Wales (NSW) are eligible for an annual registration fee rebate. Select the annual registration fee applicable depending on your principal place of practice and calculate the total payment amount. Assessment Fee Application Fee Registration Fee

Cheque/Money order (payable to Australian Health Practitioner Regulation Agency)

Go to question 32 You must attach cheque or money order.

Cash/EFTPOS (only available if paying in person)

Go to question 32

$220.00

+ $115.00

+ $
PAYMENT AMOUNT

=
Item Fee for annual registration National Fee 115

$
Fee for NSW registrants* 104

Rebate for NSW registrants*

11

Registrants whose principal place of practice is New South Wales pay the national fee less the rebate from the NSW government. The registration period for the Nursing and Midwifery profession is 1 June to 31 May. The renewal date for the profession is 31 May. Applicants are always required to pay 100% of the annual registration fee. If the application is made in the first 10 months of the registration period applicants will be registered until the renewal date of the current year. If the application is made within the last two months of the registration period, applicants will be registered until the renewal date of the following year.

Credit / Debit Card Payment Slip - Please fill out

Amount payable

$
Visa MasterCard Cardholders signature Visa or MasterCard number

SIGN HERE
Cardholders name

Expiry date

MM
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Y Y
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*AGOS-4010*
SECTION K: Checklist
32. Have the following items been attached or arranged if required?
Certified copies of all documents that provide sufficient evidence of your identity Question 9 A certified photocopy of your passport Question 9 A certified photocopy of your licence Question 10 Certified copies of all your relevant academic qualifications Question 11 A separate sheet with additional qualifications Question 11 Certificate of Registration Status or Certificate of Good Standing Question 12 A separate sheet with additional registration details Question 12 Statement of Service from your employer(s) over the last 5 years Question 13 Your Curriculum Vitae Question 13 A separate sheet with an explanation of circumstances of your criminal history in Australia Question 14 A separate sheet with an explanation of circumstances of your criminal history overseas Question 15 A separate sheet with your impairment details Question 19 A separate sheet with your suspension or cancellation details Question 20 A separate sheet with your suspension, cancellation or refusal details Question 21 A separate sheet with your conditions, undertakings or limitations details Question 22 A separate sheet with your disqualifications details Question 23 A separate sheet with your conduct performance or health proceedings Question 24 Evidence that you have maintained continous professional practice Question 25 Evidence of the successful completion of an approved English language test has been requested from relevant authority Question 27 Evidence of maintaining continuous practice, employment or enrolment in a program using English as the primary language Question 28

33. Has the associated fee been paid or attached?

Application fee Completed Visa or Mastercard details provided or cheque or money order attached Registration fee Completed Visa or Mastercard details provided or cheque or money order attached

Please post this form with payment to: AHPRA GPO Box 9958 IN YOUR CAPITAL CITY You may contact the Australian Health Practitioner Regulation Agency on 1300 419 495 or you can lodge an enquiry at www.ahpra.gov.au OFFICE USE ONLY

Receipted (stamp here)

Processed by: Approved by:

Date scanned: Amount payable:

DD / MM / YYYY

$
Visa Date Date MasterCard

DD / MM / YYYY DD / MM / YYYY

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