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APPLICATION FORM

To Be Filled By Capital Letters In English (* Indicates Mandatory)

STUDENT’S NAME

FATHERʼS NAME

MOTHERʼS NAME

PRESENT ADDRESS

HOUSE NUMBER

ROAD NUMBER

PO.

THANA

DISTRICT

POSTAL CODE

PERMANENT ADDRESS

HOUSE NUMBER

ROAD NUMBER

PO.

THANA

DISTRICT

POSTAL CODE

STUDENT’S MOBILE NO

STUDENT’S EMAIL

FIRST GUARDIAN MOBILE NUMBER

RELATIONSHIP WITH FIRST GUARDIAN

DATE OF BIRTH

PLACE OF BIRTH

GENDER

BLOOD GROUP

RELIGION

PASSPORT NUMBER

PASSPORT ISSUE DATE

YEAR OF EXAM

NAME OF INSTITUTE

BOARD/CITY

Result

EXPERIENCE OF NURSING

IF YES, PLEASE SPECIFY

SELECT YOUR SUB-AGENT

DECLARATION:

Have you ever been convicted by any court of law whether in Singapore or elsewhere, of any offences?

IF YES, PLEASE SPECIFY

Have you ever been the subject of adverse finding(s) in proceedings before any professional body or tribunal whether in Singapore or elsewhere*?

IF YES, PLEASE SPECIFY

Are you currently or have you ever been the subject of any proceedings, inquiry or investigation, by any authority or institution (including educational institution), professional or regulatory body, licensing or health authority the police, or any other law enforcement agency, in Singapore or elsewhere, the subject matter of which may give rise to concerns relating to professional misconduct, your professionalism and/or your behaviour which may affect your suitability and fitness to practise in the profession?
Examples of concerns that could arise during your education include cheating, plagiarism, theft, falsifying documents, reports or records, assault, harassment and drug or sexual offences.

Select Your Answer Below

IF YES, PLEASE SPECIFY

Are you currently or have you ever been the subject of an inquiry or proceedings by a professional body Health Authority or court of law in Singapore or elsewhere, involving or relating to any physical or mental illness suffered by you?

Select Your Answer Below

IF YES, PLEASE SPECIFY

Have you ever suffered or are you suffering from any physical or mental illness or any other condition which may impair your fitness to practise as a nurse/midwife?

Select Your Answer Below

IF YES, PLEASE SPECIFY

Are you currently undergoing psychiatric treatment?

IF YES, PLEASE SPECIFY

Acceptance 1

I declare that the particulars stated in this application and the documents attached are true, correct and complete and the information contained herein remains true, correct and coplete to date. I undertake to inform INA of any data discrepancy (e.g inaccurate/outdated data) and I am aware that I may be asked to provide more information to the INA, If necessary. To the best of my knowledge and belief, I have not withheld any material fact.

Acceptance 2

I acknowledge that the INA reserve all rights to withhold registration or to remove my name from the appropriate register and/or take any action it deems fit. I also understand and give my consent for the INA to make any enquiries or to obtain any information & documents whice it may require to verify my qualifications and fitness to practise.

Acceptance 3

I acknowledge that the INA reserve all rights to receive, collect and/or tranmit the avove personal data or other authorities or argencies if required to do so for the purpose of carrying out its under the Nurses & Midives Act (NMA) and/or for compliance with any other Acts and subsidary legislations. I also acknowledge that INA is not liable for any damage or loss caused to me in couse of my using the Professional Registration System (PRS) due to data errors in the personal data I provide. The personal data collected will be kept in the strictest confidence and access restricted only to authorised persons. To safegaurd all personal data, all electronic storage and transmission of personal data are secured through appropriate security technology.

Acceptance 4

I agree to allow this application including all of the information contained, and declarations set out, in this application to be accessed by prospective employer.

Below Mentioned Objectives (attested) must be attached with the application.

Valid Passport

passport size photos

Educational Certificates

National ID card/Birth Certificate

Training Certificate (If any)

Please type your name here to certify that all the information on this form is true and correct

Please type the name of your Parent/Guardian here to certify that they are aware and give permission