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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