FORM A - Ministry of Health

"Protecting the Health and Well Being of the Public"

FORM-A

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

Ong Sum Ping Condominium, Ong Sum Ping, BA1311 Bandar Seri Begawan Brunei Darussalam

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

Fax: +6732230024

APPLICATION FOR ADMISSION TO THE REGISTER

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.

Completing this 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 :

REGISTRATION NUMBER -

Click HERE to reset form

SECTION A

Full Name

(As per Brunei ID card)

Brunei ID

-

Color: Yellow

Red

DOB

d d m m y y y y Age

Nationality

Green

Passport No Country of Birth

Country of Issue

Sex: Male

Female

Race

Marital Status: Single

Married

Divorced

Widowed

Religion

PASTE PHOTO HERE

Home Address: Mailing Address:

HP e-mail: PAGE1

CONTACT INFORMATION

Post Code

Home

Contact Number

Post Code Others

NBB/FEB2016

NURSING AND / OR MIDWIFERY QUALIFICATION(S)

Professional Qualification

Institution

Country

Programme Duration

d dmm y y y y

to

d dmm y y y y

d dmm y y y y

to

d dmm y y y y

d dmm y y y y

to

d dmm y y y y

d dmm y y y y

to

d dmm y y y y

d dmm y y y y

to

d dmm y y y y

d dmm y y y y

to

d dmm y y y y

d dmm y y y y

to

d dmm y y y y

SECTION B : APPLICATION FOR PRACTISING CERTIFICATE (PC)

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 (i.e Unit/Ward/Department)

Address

Position

Postcode (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

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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 Brunei Darussalam or another country?

Yes No

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

Yes

No

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?

Yes No

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

Yes No

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 professional misconduct of any improper conduct which brings disrepute to the nursing profession?

Yes No

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

Yes No

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

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NBB/FEB2016

CHECKLIST OF SUPPORTING DOCUMENTS REQUIRED (CERTIFIED TRUE COPY)

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) 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.

ATTACHED

SECTION C

FOR OFFICIAL USE ONLY

Type of Registration endorsed by the Board

Registered Nurse

Registered Assistant Nurse

Registration Fee,

$75

Certificate of Registration

(CoR) & Badge

Practising Certificate Fee $25

Receipt No

Practising Certificate Receipt No

*Registered Midwife

Fee exempted

Date : d d m m y y y y

Date : d d m m y y y y

Issue Date

Expiry Date

Signature and stamp:........................................................

Date.....................................

Remarks : ................................................................................................................................. ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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NBB/FEB2016

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