IHNA-Form-AF-RBPOQRN
Mr Mrs Miss Ms Other:………..
Your name must appear on this application exactly as it appears in your passport
MAILING ADDRESS:
Do not use PO Box and advise IHNA if you change your address during the year
Family Name:
Given Name:
Other/Middle Name:
Female Male
Date of Birth: DD/MM/YYYY Country of Birth:
No. and street:
Suburb/City:
State: Zip/Postcode:
Country:
Telephone:
Fax:
Mobile:
*Email:
PERMANENT ADDRESS:
If not the same as the Mailing Address No. and street:
Suburb/City:
State: Zip/Postcode:
Country:
Telephone:
Fax:
Mobile:
*Email:
1. PERSONAL DETAILS.
2. AGENT DETAILS
Are you applying through an agent?
Yes No
Include agent stamp in the box below
Is your agent an authorised agent of IHNA?
Yes No Don’t know
AGENT’S STAMP HERE
IHNA Reference. (For office use only)
3. INTAKE AND VISA DETAILS
Which intake do you intend to apply for?
Year: Month:
Do you have Australian Permanent Residency (PR) status?
Yes If Yes, please provide evidence of this status with your application form.
No If no, what is the type of visa you currently hold [please provide evidence] No If yes, year you are likely to gain PR: YYYY
Citizenship:
Country of Application:
4. ENGLISH LANGUAGE PROFICIENCY
Is English your first language?
Yes No
Was English your language of instruction at secondary and tertiary level?
Yes No
International applicants must provide
documented evidence of completing one of the following English proficiency tests.
Tick the one you are providing. IELTS Academic:
achieving an overall minimum score of 7.0 with minimum individual score of 7.0 in writing, speaking, reading and listening;
or OET:
Nursing version level ‘B’ or above in a single sitting.
Date of Test: D D/M M/Y Y Y Y Institution:
Overall Score Achieved:
Listening Score: Writing Score:
Reading Score: Speaking Score:
5. FINANCIAL SUPPORT
Please indicate your source of financial support and for invoice purposes please attach infor- mation of person or organisation paying fees.
I am fully sponsored by my home govern- ment (attach documentation)
I am fully sponsored by an employer (attach documentation)
I am a private student supported by myself/
my family
I am a private student supported by an approved bank loan
6. HOW DID YOU HEAR ABOUT IHNA ?
Internet Agent:
Friend/relative:
Advertisement:
Other:
7. DISABILITY
Do you have a disability? Yes No If Yes, please state:
IHNA-Form-AF-RBPOQRN
8. NURSING QUALIFICATIONS
8a. You are qualified as :
Registered Nurse Mental Health Nurse Midwife Enrolled Nurse Graduate Nurse 8b. List below all your Nursing Qualifications.
Attach certified copies of your Nursing Graduation Certificate, Diploma or Degree as well as the transcript or academic record showing your grades for the nursing diploma or degree.
Experience date is considered from the date of Nursing Registration. See Checklist on Page 5.
Qualification Type of Certificate/Award &
Institution
Country of Qualification and Language of
instruction
Duration of Course From To
8c. List below your experience as a qualified nurse.
Please supply statements from employers and a reference. See Checklist on Page 5
Employer Position Held Area of Experience Duration
From To
.
9. REGISTRATION
9a. Where were you first registered?
Please supply a certified copy of your initial registration:
Country:
Registering Authority:
Registration Number:
Date of Registration:
9b. Have you ever been registered in Australia?
Yes No
9c. Are you currently registered?
Yes (give details below) No Country:
Registering Authority:
Registration Number:
Date of Registration:
10. OTHER RELEVANT PROGRAMS, TRAINING OR STUDIES
UNDERTAKEN
I declare that:
to the best of my knowledge, the information provided by me is true and complete.
I acknowledge that the Institute of Health and Nursing Australia may vary or reverse any decision regarding admis- sion or enrolment made on the basis of incorrect or incomplete information
provided by me.
I understand that I am seeking temporary entry into Australia for educational purposes only.
I authorise the IHNA to make enquiries about the details associated with this application.
I understand the above conditions and am prepared to accept them in full.
I understand that I, or my sponsor, will be responsible for the full cost of the program for which I am seeking admission, as well as travel and living costs.
I understand that, as part of the program, I will need to travel to health facilities for clinical placement and all cost associated with travelling and accommodation shall be borne by me.
Date : DD/MM/Y YY Y
11. DECLARATION
IHNA-Form-AF-RBPOQRN
12. CHECKLIST
COMPLETE THE CHECKLIST BELOW AND ATTACH ALL RELEVANT DOCUMENTS TRANSLATION OF DOCUMENTS:
If documents are in a language other than English, you must have them translated by an official translator before sending them to us. Once the documents have been translated, both the translation and the documents in the original language, should be sent with this application form.
CERTIFIED COPIES:
If applying by mail, each copy of an original document must bear a statement certifying that it is a true copy of the original by a Lawyer, Justice of the Peace, Peace Commissioner, Commissioner of Oaths, Notary Public, Judge, Magistrate, a member of the Australian Immigration Department,
Australian Embassy or Consulate. The person who signs the document must have the legal authority to do so and the statement should also include the appropriate official stamp or seal. It should also include the date of the statement and the name, signature, business contact address and business phone number of the person making the statement.
CHECK LIST
Certified copies showing completion of training diploma or degree.
Current registration certificate with the Nursing Board.
Post basic certificates and statements of aca- demic record issued by any other higher education institutions.
Document confirming your date of birth:
A certified copy of your birth certificate should be provided as proof of date of birth. If you are unable to supply a birth certificate, please supply a certi- fied copy of your passport.
Letter from Nurses Board of Victoria/ AHPRA/
NMBWA/ACTNMB confirming acceptance to under- take initial registration program.
Evidence of change of name:
If the name on any of your documents is not the same as that on the birth certificate, you will need to supply a certified copy of one of the following as evidence of your change of name: marriage certifi- cate, divorce papers or deed poll.
English proficiency – original or certified copy:
See Section 2 for English language proficiency tests accepted for entry to Initial Registration Program
Certified copy of nursing graduation certificate, diploma or degree
Certified copy of initial registration Resume / CV
Minimum 2 Years Nursing Experience with a Minimum of one year experience in a Medical or Surgical ward
Professional reference – original or certified copy:
One professional reference (dated within the last two years and on official letterhead), which includes the following:
Dates of employment
Areas of experience
A statement of your professional competence as a nurse/midwife
Name, signature and position of the referee Employment statements – original or certified copy:
Statements from employers on official letterhead giving dates of employment (must be within the last five years), your area of expertise and where you were working.
Passport – certified copy:
You should supply a certified copy of the page (s) of your current passport verifying your legal name and personal details.
Certified copy evidence of Visa
Permanent Resident Status Candidates only If you have gained Permanent Residency status in Australia, you should supply evidence of attaining your PR status – a certified copy of the page (s) in your current passport verifying your Permanent Residency Status visa.
Candidates who do not have PR status can disre- gard this item on the checklist.
PLEASE NOTE THAT DOCUMENTS YOU SUBMIT TO IHNA FOR ASSESSMENT
ARE NOT RETURNABLE.
