application form

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APPLICATION FORM
Nursing Education Centre
Acute Nursing Transition (ANT) Program
When completed please save and send as an attachment to [email protected]
______________________________________________________________________
A. Personal details
Date of application: Click here to enter a date.
Name:
(given name)
(family name)
(preferred name)
Address Line 1:
Address Line 2:
Suburb:
Contact Phone No:
Postcode:
Email:
Are you an Australian citizen or have permanent residency?
Yes
No
Are you willing to undergo a National Police Record Check prior to commencement of the program?
Yes
No
______________________________________________________________________
B. Initial nursing qualifications and registration
Where did you complete your initial registration course? Hospital
University
What is the name of University or hospital?
What year did you complete your initial registration course?
What is your Nursing Midwifery Board of Australia Registration? NMW
______________________________________________________________________
C. Employment history
List current and past employment, including dates and positions held:



______________________________________________________________________
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D. Professional development
List professional development completed post initial registration, including dates:



______________________________________________________________________
E. Referees
List 2 professional referees and contact details:
1.
2.
______________________________________________________________________
Additional application questions
Q. Why would you like to undertake our Transition program ? (maximum 250 words)
Q2. What are the key objectives or skills that you would like to achieve upon completion of our program
(maximum 250 words)
Q3. What clinical areas are of particular interest to you? (maximum 100 words)
Please save and send as an attachment to [email protected]
______________________________________________________________________
Nursing Education Centre
St Vincent’s Hospital
Level 2, Aikenhead Wing
PO Box 2900
Victoria Parade, Fitzroy VIC 3065
Tel:
03 9231 3561
Email: [email protected]
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