EQUIVALENCE | SNP
Attestation of Professional Experience as a Nurse
Office of the Admissions and Registrar
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IDENTIFICATION OF THE APPLICANT
Permit number:
Last name:
First name:
Birth name:
Date of birth:
If different from the family name
Address:
City (Province):
Email:
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Country:
Postal code:
Telephone:
EMPLOYER
This section must be completed by the employer.
Name of the employer:
Address:
City (Province):
Country:
Postal code:
Representative
Last name:
First name:
Title:
Email:
Certifies that the applicant identified above has been employed by us.
Telephone:
Employee number:
Start date:
End date:
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O I certify the accuracy of the information contained in this application.
O I authorize the Ordre des infirmières et infirmiers du Québec to proceed with its verification if necessary.
Signature:
Date of signature:
Please affix your seal or
stamp in this space
The form must be completed, signed, and returned to the applicant.
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EQUIVALENCE | SNP
Attestation of Professional Experience as a Nurse
Office of the Admissions and Registrar
►►
PROFESSIONAL EXPERIENCE
This section must be completed by the employer.
Total number of hours while the applicant was employed by you:
Please indicate the number of hours worked per year as well as the area(s) the employee has worked in.
From 1 January
To 31 December
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Clinical areas*
Number of hours
*Examples of clinical sectors
Medicine
Mental health
Pediatric
Surgery
Operating room
Intensive care
Geriatrics
Perinatal care
Others
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EQUIVALENCE | SNP
Attestation of Professional Experience as a Nurse
Office of the Admissions and Registrar
►►
PROFESSIONAL EXPERIENCE [continue]
Applicant’s employment title:
The main responsibilities related to this work are:
The division of tasks is as follows:
%
Direct patient care
%
Management
%
Teaching
%
Other
If other, please specify:
A description of the applicant’s position is attached:
O Yes
O No
O Yes
O No
If No, please list the key functions below:
DESCRIPTION OF THE HEALTH CARE FACILITY
A description of the facility is attached to this form:
Address of the website of the facility:
Mission (general hospital, specialized health care facility, etc.):
Total number of beds in the institution:
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