FORM A - Ministry of Health

1 form -A. Office: Nursing Board for Brunei Website: 2G3:01, Level 3, Email: Protecting the Health and Well Being of the Public Ong Sum Ping Condominium, Tel: +673-2230025. Ong Sum Ping, BA1311 Fax: +6732230024. Bandar Seri Begawan Brunei Darussalam APPLICATION FOR ADMISSION TO THE REGISTER. This application will not be considered unless it is complete and all Completing this form supporting documentation has been provided. Only submission of Read and complete Section A and Section B (if applicable). original application form is accepted.

2 Do appear neat and tidy as Ensure that all pages and required supporting documents are your photograph will be taken at the Board. returned. All photocopied document(s) must be certified as true copies by an authorised person. Privacy and Confidentiality Use a BLUE PEN only. The Nursing Board for Brunei are committed to protecting your Print clearly in personal information as private and confidential. Place in all applicable boxes : . REGISTRATION NUMBER - Click HERE to reset form SECTION A. (As per Brunei ID card). Full Name Brunei ID - Color: Yellow Red Green DOB d d m m y y y y Age Nationality Passport No Country of Issue PASTE PHOTO HERE.

3 Country of Birth Sex: Male Female Race Marital Status: Single Married Divorced Widowed Religion CONTACT INFORMATION. Home Address: Post Code Mailing Address: Post Code Contact Number HP Home Others e-mail: PAGE1 NBB/FEB2016. NURSING AND / OR MIDWIFERY QUALIFICATION(S). Professional Qualification Institution Country Programme Duration d d m m y y y y to d d m m y y y y d d m m y y y y to d d m m y y y y d d m m y y y y to d d m m y y y y d d m m y y y y to d d m m y y y y d d m m y y y y to d d m m y y y y d d m m y y y y to d d m m y y y y d d m m y y y y to d d m m y y y y SECTION B : APPLICATION FOR PRACTISING CERTIFICATE (PC).

4 This section must ONLY be completed by those currently employed as a nurse and /or midwife in Brunei Darussalam Place of Employment in Brunei Darussalam Area of Practice ( Unit/Ward/Department). Address Postcode Position (according to current official letter of employment). Date of Employment d d m m y y y y Tel No: Employment Status: Permanent Daily Paid Contract Valid Until : d d m m y y Others : Please Specify PAGE 2 NBB/FEB2016. Declaration Please check the box that best corresponds to your answer for each question below 1. Have you ever been suspended from duty, or had a complaint upheld on your registration or license to practice removed while working as a nurse or other Health care professional in Yes No Brunei Darussalam or another country?

5 2. Have you ever been refused registration or a license to practice by any other nursing or Health Yes No professional regulator in Brunei Darussalam or another country? 3. Do you know of any reason why the nursing authority in any of the countries where you have Yes No worked since qualifying as a nurse, would refuse to grant you a certificate of good standing? 4. Has a nursing school or university ever taken any form of disciplinary action and/ or fitness to Yes No practice procedures against you? 5. Has an employer ever taken disciplinary action against you?

6 Yes No 6. Have you ever been fined, given a warning or reprimanded by other nursing or Health Yes No professional regulator in Brunei Darussalam or another country? 7. Are there, or do you know of, any current or future proceeding or other matters that might lead to your registration or a license to practice in Brunei Darussalam or any country being Yes No removed, suspended or restricted in any way? 8. Have you been or are you currently the subject of an inquiry or an investigation by any licensing or Health authority in Brunei Darussalam or elsewhere involving an allegation of Yes No professional misconduct of any improper conduct which brings disrepute to the nursing profession?

7 9. Have you ever suffered or are you suffering from any physical or mental illness, which may Yes No impairs your fitness to practice as a Nurse/Midwife? Yes No 10. Have you ever been convicted in Brunei Darussalam or elsewhere of any offence? I declare that to the best of my knowledge and belief the information provided above are true or else I am committing an offence for falsification any information under Section 9 of Nurses Registration Act, Cap 140, punishable with a fine of $6,000 and imprisonment for 12 months.. Signature Date NBB/FEB2016.

8 PAGE 3. CHECKLIST OF SUPPORTING DOCUMENTS REQUIRED (CERTIFIED TRUE COPY) ATTACHED. 1. Brunei Identity Card 2. Passport (including employment pass if applicable). 3. 1 Passport size photo 4. Letter of Employment (including date of employment). 5. Pre-Registration (Basic) Nursing /Midwifery Certificate 6. Pre-Registration (Basic) Nursing /Midwifery Transcript 7. Additional Qualification Certificate (if any). 8. Certificate of Registration from Country of Origin (for newly employed foreign nurse/midwife only). 9. Practising Certificate /License from Country of Origin / Practice (if any).

9 10. Record Clearance / Police Certificate from Country of Origin (for newly employed foreign nurse/midwife only). 11. Evidence of a change of name or other relevant details (if any). 12. Previous Employment Testimonial / Certificate of Employment (for newly employed nurse/midwife only, if applicable). 13. Medical Fitness Certificate (for newly employed nurse/midwife only). 14. *Registration Fee $75. 15. *Practising Certificate Fee $25 (if currently employed as a nurse in Brunei Darussalam). *Please bring exact amount for payment.

10 SECTION C. FOR OFFICIAL USE ONLY. Type of Registration endorsed by the Board Registered Nurse Registered Assistant Nurse *Registered Midwife Fee exempted Registration Fee, $75 Receipt No Date : d d m m y y y y Certificate of Registration (CoR) & Badge Practising Certificate Practising Certificate Fee $25 Receipt No Date : d d m m y y y y Issue Date Expiry Date Signature and stamp: .. Date .. Remarks : .. PAGE 4 NBB/FEB2016.