First Name (required):
By what name are you known
The name you want us to call you by / what do your friends call you? (required):
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Number of Dependent (s):
Passport Expiration Date:
Passport Issue Date:
Are you currently licensed to practice as a Registered Nurse in your country of
Did you complete a degree/diploma in Nursing?
In what YEAR did you FIRST qualify as a Registered nurse?
For example 2014 (WHEN YOU FIRST QUALIFIED)
Country of Training:
Years of Experience:
Describe the Unit where you currently working?
FOR EXAMPLE, I am working is a surgical ward. The ward caters for patients
undergoing a wide range of general and complex surgical procedures. The surgical
ward staff are experienced in caring for patients with postoperative complications
including pain management, wound care and nutritional needs.
General, Acute WardsGeneral, DentalGeneral, ER AcuteGeneral, Elderly CareGeneral, ICUGeneral, MidwiferyGeneral, NICUGeneral, PaediatricsGeneral, NeuroGeneral, PsychiatryGeneral, RenalGeneral, TutorGeneral, MedicalGeneral,GynecologyGeneral,OphthalmicGeneral,OrthopedicGeneral, CardiologyGeneral, SurgeryGeneral, OncologyGeneral OtherCommunity CareMidwife RegisteredPaediatric RegisteredMental Health RegisteredTheatre EndoscopyTheatre RecoveryTheatre Scrub NurseTheatre AnaestheticOtherHealth Care Assistant
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Have you ever participated in a similar program like this before?
If yes, state where:
Do you have any family and/or friends in Europe?
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Have you ever been convicted of a crime?
If yes, explain:
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Spouse's Full Name:
Who will pay for your trip?
Address of person paying for your trip:
Next of Kin/Emergency Contact Name:
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Next of Kin/Emergency Contact #:
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First Reference Name:
First Reference Occupation:
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First Reference Contact #:
First Reference Relation:
Second Reference Name:
Second Reference Occupation:
Second Reference Address:
Second Reference Contact #:
Second Reference Relation:
Third Reference Name:
Third Reference Occupation:
Third Reference Address:
Third Reference Contact #:
Third Reference Relation:
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