REGISTERED NURSES' ASSOCIATION OF NOVA SCOTIA

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