This application will not be considered unless it is complete and all supporting documentation has been provided. Only submission of original application form is accepted. Do appear neat and tidy as your photograph will be taken at the Board.

Privacy and Confidentiality The Nursing Board for Brunei are committed to protecting your personal information as private and confidential.

APPLICATION FOR ADMISSION TO THE REGISTER Completing this form

REGISTRATION NUMBER -

(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

Country of Birth Sex: Male Female Race

Marita l Status: Single Married Divorced Widowed Religion

SECTION A

“Protecting the Health and Well Being of the Public”

Office: Nursing Board for Brunei 2G3:01, Level 3,

Ong Sum Ping Condominium, Ong Sum Ping, BA1311

Website: www.moh.gov.bn Email: nursing.board@moh.gov.bn Tel: +673-2230025

Fax: +6732230024 Bandar Seri Begawan

Brunei Darussalam

FORM-A

PASTE PHOTO HERE

NBB/FEB2016

CONTACT INFORMATION

Home Address:

Post Code

Mailing Address:

Post Code

Contact Number HP Home Others

e-mail:

PAGE1

Click HERE to reset form

• Read and complete Section A and Section B (if applicable).• Ensure that all pages and required supporting documents are

returned.• All photocopied document(s) must be certified as true copies by

an authorised person.• Use a BLUE PEN only.• Print clearly in• Place in all applicable boxes :

This section must ONLY be completed by those currently employed as a nurse and /or midwife in Brunei Darussalam

NURSING AND / OR MIDWIFERY QUALIFICATION(S)

Professional Qualification Institution Country Programme Duration

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

d d m m y y y y

SECTIO N B : APPLICATION FOR PRACTISING CERTIFICATE (PC)

Place of Employment in Brunei Darussalam

Area of Practice (i.e 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

1. Have you ever been suspended from duty, or had a complaint upheld on your registration orlicense to practice removed while working as a nurse or other health care professional inBrunei Darussalam or another country?

Yes

2. Have you ever been refused registration or a license to practice by any other nursing or healthprofessional regulator in Brunei Darussalam or another country?

worked since qualifying as a nurse, would refuse to grant you a c ertificate of good standing?

4. Has a nursing school or university ever taken any form of disciplinary action and/ or fitness topractice procedures against you?

5. H as an employer ever taken disciplinary action against you?

6. Have you ever been fined, given a warning or reprimanded by other nursing or healthprofessional regulator in Brunei Darussalam or another country?

7. Ar e there, or do you know of, any current or future proceeding or other matters that might leadto your registration or a license to practice in Brunei Darussalam or any country beingremoved, suspended or restricted in any way?

8. H ave you been or are you currently the subject of an inquiry or an investigation by anylicensing or health authority in Brunei Darussalam or elsewhere involving an allegation ofpr ofessional misconduct of any improper conduct which brings disrepute to the nursingprofession?

impairs your fitness to practice as a Nurse/Midwife?

10. H ave 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

PAGE 3 NBB/FEB2016

Please check the box that best corresponds to your answer for each question below

3. D o you know of any reason why the nursing authority in any of the countries where you have

9. H ave you ever suffered or are you suffering from any physical or mental illness, which may

No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes

Yes

Yes

No

No

No

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. A dditional Qualification Certificate (if any)

10. Record Clearance / Police Certificate from Country of Origin (for newly employedforeign nurse/midwife only)

8. Certificate of Registration from Country of Origin (for newly employed foreign nurse/midwife only)

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)

FOR OFFICIAL USE ONLY

Type of Registration endorsed by the Board

Registered Nurse Registered Assistant Nurse *Registered Midwife

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 : ………………………………………………..…………………………..………………………………….. …………………………..…………………………..…………………………..………………………………………... …………………………..…………………………..…………………………..………………………………………… …………………………..…………………………..…………………………..…………………………………………

SECTION C

PAGE 4 NBB/FEB2016

*Please bring exact amount for payment.

11. Evidence of a change of name or other relevant details (if any)

Fee exempted

9. Practising Certificate /License from Country of Origin / Practice (if any)