GENRAL NURSING COUNCIL, GUYANA - Imagodeildc
Name: ……………………………………………………………………………………………………
(In Block Letters) Surname First Second
Date of Birth: ………………………………………………………………..
Home Address: ...............................………………………………………………………………….
…………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Temporary Address: …………………………………………………………………………………….
(in Guyana) ……………………………………………………………………………………
…………………………………………………………………………………….
State whether Single or Married: ……………………… Maiden Name: ……………………………..
Project/Company or: …………………………………………………………………………………….
Hospital of Attachment: …………………………………………………………………………………….
&
Telephone Number: ………………………………………………………………………………………
Seeking Registration as: Nurse Practitioner/Nurse/ Midwife/ Nursing Assistant
(Please tick)
Period of Stay in Guyana: From: ………………………. To: ……………………………………..
NB: You are required to produce an Original or certified copy of current Registration Before Temporary Registration is Granted.
Registration will be valid for a period of six (6) months only after which it MUST be renewed.
FEE: ------------------
DATED: ……………………………………… …………………………………………………
Signature of Applicant
Signature of Witness: ……………………………………………………
Address of Witness: ……………………………………………………………
All applications must be accompanied by notarized copies of the following supporting documents: 1) Passport Photo, 2)Copy of current license
3) Copy of Medical Diploma
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