REGISTERED NURSES' ASSOCIATION OF NOVA SCOTIA

College of Registered Nurses of Nova Scotia – Registration ServicesSuite 4005, 7071 Bayers Rd. Halifax NS, Canada B3L 2C2Telephone: 1-902-491-9744, ext 252 Toll Free: 1-800-565-9744 Facsimile: 1-902-491-9510E-mail address: ien@crnns.ca Website: www.crnns.caAPPLICATION FOR INITIAL REGISTRATION ASSESSMENT FOR IENSWHO HAVE NEVER BEEN REGISTERED IN CANADApart i - I hereby apply for registration as a registered nurse in Nova Scotia under the terms of the Registered Nurses Act(2006).Please return the completed application to the College at the address noted above, with proof of legal name, photo ID andnon-refundable assessment fee of $460.00 (Canadian funds, includes HST). Payment can be made by internationalmoney order or online by credit card. We do not accept international demand drafts or cheques.Note: Your application will not be processed without receipt of fee.A. Personal Information - Show given names in full.Surname – Print in Block Letters First Name Middle NameBirth Name Former Name(s) Date of Birth (M/D/Y)Permanent Mailing Address City/Town Province Postal Code CountryWhat is your first language?B. Initial Nursing EducationName of School of Nursing Address City/Town Province CountryProgram Started (Month/Year)Program Completed (Month/Year)C. List highest education level attained following initial nursing educationProgram Name of Institution Program Started/Completed (Month/Year)D. Nurse Registration - List original jurisdiction and all jurisdictions where you currently hold or have held an activepractisinglicence. List the most recent province/country of licensure first:Province, State orCountryRegistration #Current Status(Active/Non-Active)Date Issued(Month/Year)Date Expired(Month/Year)Rev 11/10

College of Registered Nurses of Nova Scotia – Registration ServicesSuite 4005, 7071 Bayers Rd. Halifax NS, Canada B3L 2C2Telephone: 1-902-491-9744, ext 252 Toll Free: 1-800-565-9744 Facsimile: 1-902-491-9510E-mail address: ien@crnns.ca Website: www.crnns.caE. Status of Registration1.Have you ever been charged with, pleaded guilty to, been convicted of or found toYes No If yes, explainbe guilty of an offence in or out of Canada, for which you have not received apardon?2.Are you currently under investigation by any registration/licensing authority? Yes No If yes, explain3.Do you currently hold a licence with another health profession? Yes No If yes, explain4.Have you ever been disciplined by a registration/licensing authority forany occupation/profession in or out of Canada, or do you have anyconditions or restrictions on any licence that you currently hold?Yes No If yes, explain5.Have you ever been denied or had revoked any registration, licence, or permit? Yes No If yes, explain6.Were you ever disciplined by or expelled from any university or school of nursing? Yes No If yes, explain7.Have you ever been suspended or terminated from any employment? Yes No If yes, explain8.Is there, to your knowledge or belief, any event, circumstance or conditionconcerning your competence, character, capacity, conduct or reputation thatmay impact your registration as a registered nurse?IF ANSWERING “YES” TO QUESTIONS 1-8, PLEASE ATTACH AN EXPLANATION.9.Have you ever written the Canadian Registered Nurse Examination (RN exam)for registration in another Canadian jurisdiction?Yes No If yes, explainYes No If yes, explain10.Have you ever been required / asked by another regulatory body in Canada tocomplete a competence assessment? (e.g., a competence assessment of yourknowledge, skills and abilities using tools such as observation, interviews andwritten tests.)?11.Have you ever completed a competence assessment in another Canadian jurisdiction? Yes NoIf you answered yes to question #11, please arrange for a certified true copy of thefollowing to be forwarded to the College from the regulatory body as applicable:•all letters associated with the process;•the assessment report; and•transcripts of education completed to bridge the gaps identified in theassessment report.F. Nursing PracticeYes NoIf yes, answer question #11Please record the total number of actual hours worked as a registered nurse from November 1 to October 31 for thecurrent and previous five years.20 - hours (current year, to date of application) 20 - hours (three years previous)20 - hours (one year previous) 20 - hours (four years previous)20 - hours (two years previous) 20 - hours (five years previous)Rev 11/10

College of Registered Nurses of Nova Scotia – Registration ServicesSuite 4005, 7071 Bayers Rd. Halifax NS, Canada B3L 2C2Telephone: 1-902-491-9744, ext 252 Toll Free: 1-800-565-9744 Facsimile: 1-902-491-9510E-mail address: ien@crnns.ca Website: www.crnns.caHave you taken a nursing re-entry program in the last five years? Yes NoIf yes:Name of programLocationDate completedG. Nursing Experience Following Graduation - Complete contact information of two most recent employers:ImmediateSupervisor &Position TitleFacility NameFacility AddressFacility E-mail &Telephone #Dates of EmploymentH. Applicant’s Current Mailing AddressStreet AddressCity/Town Province/State Postal Code CountryE-mail address Telephone #Rev 11/10

Signature DeclarationCollege of Registered Nurses of Nova Scotia – Registration ServicesSuite 4005, 7071 Bayers Rd. Halifax NS, Canada B3L 2C2Telephone: 1-902-491-9744, ext 252 Toll Free: 1-800-565-9744 Facsimile: 1-902-491-9510E-mail address: ien@crnns.ca Website: www.crnns.caBy signing this application form:I authorize the collection, use and disclosure of personal information concerning myself as described in theCollege of Registered Nurses of Nova Scotia (CRNNS) Privacy Policy Statement available at: http://www.crnns.ca/default.asp?id=190&sfield=content.id&search=2924&mn=414.1116.1137.In addition, I authorize CRNNS to carry out the procedures necessary for the assessment of my eligibility forregistration. This includes making copies of my application documents for the purpose of assessment and/orcontacting the institutions or authorities stated on this application to verify the authenticity of my documentsand the information provided regarding the educational institutions, regulatory bodies, and employers listed inmy application. This allows the CRNNS to contact other regulatory bodies and obtain information pertinent tomy application. I agree that a copy of this Signature Declaration can be sent by the CRNNS to other regulatorybodies allowing them to release information to the CRNNS.I declare that all of the information I have provided in my application is complete and truthful.I understand that CRNNS will immediately stop the assessment of my application and that my application forassessment will be cancelled, registration will be refused, and I will be prohibited from applying to the CRNNSin the future if:1.I have provided any inaccurate information or2.I have omitted required information; or3.the CRNNS determines that any documents submitted during the application or assessment processhave been altered, tampered with or forged.This applies to all documents received during the application process, including educational transcripts,verifications of registration and written correspondence. The CRNNS will not issue a refund and will retain alldocuments submitted with my application.I understand that in order to practice nursing in Nova Scotia, I am required by law to hold a licence withCRNNS, before I commence employment, including any orientation.I understand that this application for assessment of eligibility for registration/licensure will be considered lapsedwhen the Part I and application fee submitted to the College is more than 24 months old and I have not been incontact with the College for 12 months or more. Should my file lapse, I understand I will be required to submit anew application form, initial assessment fee and updated documentation, and that if I do not re-apply, my filedocuments will be securely destroyed five (5) years after the date they are considered lapsed.I have read and understand the above and the information on this form and agree to the terms stated herein.Signature of ApplicantDatePrint Full NameRev 11/10