This is the Employment form of NNAS. PDF is generated based on the details you enter
Nursing Practice / Employment Form
The following information from your application identifies you to the nursing organization/employer in the jurisdiction
where you have been employed over the past [1-5] years.
Please ensure that the information is correct, and sign and date each copy of this form. All forms (one for each
nursing organization/employer in the jurisdiction where you have been employed) must be mailed directly to NNAS.
Part A: PERSONAL INFORMATION
NNAS ID number: 111111 Application number: 2222
First/Given name Middle name Last/Family name
John Doe
· Your other names:
Mailing Address
Mississauga, Ontario
Canada
· Date of Birth:
00/0/1900
· Name of the facility or organization where employed:
******* Hospital
Address of Employer
Dubai
United Arab Emirates
· Name of supervisor:
John Fon
· Title/Position of supervisor:
OT Manager
I hereby give my consent to you to provide the information requested in Part B of this form related to my Nursing
Employment with this organization directly to NNAS at the following address:
NNAS
P. O Box 8658
Philadelphia, PA 19101-8658
USA
Your signature: __________________________________________________ Current date: _______________
(Please sign your name) (Provide date in DD-MM-YYYY format)
Part B: EMPLOYER INFORMATION
Please provide the following information (in English) concerning the nursing practice/employment of this
nurse. Please mail this form directly to NNAS at the provided address.
Job title or position held by this nurse: __________________________________________________________
(Provide the complete title of the job or the position held by this nurse)
Job status - Choose from the following list: ____ Full-time ____ Part-time ____ Casual ____ Other, (explain): ___________
Name of the practice setting area or unit in which this nurse worked - Choose the formal name of nursing area or unit of
practice where this nurse worked from the following list: ____ Medicine____ Surgery ____ Obstetrics ____ Psychiatry-Mental
Health ____ Paediatrics/Children ____ Geriatrics ____ Community ____ Other, (explain): _______________________
Type of patient population in the area or unit nurse worked: ________________________________________
Number of total nursing practice hours for each of the last five years worked (as applicable): _________ Year 1,
_________Year 2, __________ Year 3, __________Year 4, and __________ Year 5
Date when this nurse started employment: _______________
Date when nurse ended his/her last shift of employment: ______________
Date when this nurse ended employment: ________________
Employment category/type: Choose from the flowing list: _____ Licensed Practical Nurse, _____ Enrolled Nurse, _____
Registered Psychiatric Nurse, _____ Registered Mental Health Nurse, _____ Registered Nurse, _____ other (explain):
_____________________________________________________________________________________________________
Has this nurse ever been disciplined or allowed to resign: Choose _____ Yes, or _____ No
What is the primary language used in this nurse's practice setting: ______________________________________
What is the primary language of the patient population for which this nurse provided nursing services: ____
__________________________________________________________________________________________________
Part C: IDENTIFICATION OF EMPLOYER SUPERVISOR
Please provide the following information for the official/supervisor authorized to provide the employment information
on this nurse.
Your printed name: __________________________________________________________________________
(Please print your complete name)
Your title: __________________________________________________________________________________
(Please indicate your official title)
Your signature: ___________________________________________________ Current date: ______________
(Please sign your name) (Provide date in DD-MM-YYYY format)
Phone number: ________________________________________ Alternate phone number: ______________
(Provide your number in format: 123-456-7890 and country code if outside Canada.) (Provide an alternate number where you c
an be reached, if necessary)
E-mail address: ______________________________________________________________________________
(Please provide your personal e-mail address where you can be reached if there are questions about this information.)
All information added to this form, or attached to this form is confidential.