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APPLICATION FOR NURSE RECRUITMENT

1. Have you ever applied to CGFNS or ICHP?
Yes CGFNS/ICHP ID number:
No  
2. Name:
First
Middle
Last (in ALL capital letters)
3. Other names (family name before marriage and/or name misspellings from school documents)
4. Your mother's name at birth (name before marriage):
5. Your date of birth (mm/dd/yyyy):
6. Sex: Female
Male
7. US Social Security No. (if any):
8. US Alien Registration No. (if any):
9. Current Mailing Address:
No. and Street
City or town
Province or State
Country
Zip code or Pin code
10. Telephone Numbers (with country and city codes):
Home
Work (if any)
Fax (if any)
11. E-mail address (if any)
12. Place of birth
City
State
Country
13. Current Citizenship (country)
14. Marital Status:
15. Please list below all schools attended prior to college level studies, (including primary, elementary, secondary, higher secondary and/or pre-university, high school, etc.) You must indicate the MONTH and YEAR started AND ended for each and every school:
School 1 name
School location:
City
State
Country
Level of study
Mo/Yr Started
Mo/Yr Ended
Name of Completion Certificate
School 2 name
School location:
City
State
Country
Level of study
Mo/Yr Started
Mo/Yr Ended
Name of Completion Certificate
School 3 name
School location:
City
State
Country
Level of study
Mo/Yr Started
Mo/Yr Ended
Name of Completion Certificate
School 4 name
School location:
City
State
Country
Level of study
Mo/Yr Started
Mo/Yr Ended
Name of Completion Certificate
16. Please list below all professional/higher education schools attended (including college, university, nursing school, and technical school, etc.) List all schools attended, even if you did not graduate from that school! You must indicate MONTH and YEAR started AND ended for each and every school:
School 1 name
School location:
City
State
Country
Field of study
Mo/Yr Started
Mo/Yr Ended
Name of Degree Received
School 2 name
School location:
City
State
Country
Field of study
Mo/Yr Started
Mo/Yr Ended
Name of Degree Received
School 3 name
School location:
City
State
Country
Field of study
Mo/Yr Started
Mo/Yr Ended
Name of Degree Received
School 4 name
School location:
City
State
Country
Field of study
Mo/Yr Started
Mo/Yr Ended
Name of Degree Received
17. Date of graduation from Nursing school:
18. Nursing Registration/License Information (Ex: Registered Nurse/Midwife):
Title and country of current registration:
Title and country of first registration:
Has your registration ever been revoked?
Yes Please explain.
No  
19. Have you ever passed the US National Nursing Council Licensure Exam (NCLEX)?
Yes
State
Registration number
No  
20. WORK EXPERIENCE- begin with current position and then list ALL previous jobs in reverse chronological order. You must explain all gaps in your job history. (ex: took time off to get married or have children):
Current Employer's Name:
Employer's Address:
Date Started (mo/yr):
Job Title:
Supervisor's name:
Unit(s)/Dept.
Hours worked per week:
Describe in detail the duties performed:
Previous Employer's Name:
Employer's Address:
Date Started (mo/yr):
Job Title:
Supervisor's name:
Unit(s)/Dept.
Hours worked per week:
Describe in detail the duties performed:
Previous Employer's Name:
Employer's Address:
Date Started (mo/yr):
Job Title:
Supervisor's name:
Unit(s)/Dept.
Hours worked per week:
Describe in detail the duties performed:
Previous Employer's Name:
Employer's Address:
Date Started (mo/yr):
Job Title:
Supervisor's name:
Unit(s)/Dept.
Hours worked per week:
Describe in detail the duties performed:
21. Information about your spouse:
His/her full name:
First
Middle
Last
His/her current mailing address:
No. and street
City or Town
State or Province
Country
Zip Code or Pin Code
His/her birth date (mm/dd/yyyy)
His/her place of birth:
City
State
Country
his/her present nationality or citizenship (country):
his/her US Social Security no. (if any):
his/her US Alien Registration no. (if any):
22. Information concerning your children: NOTE: Please include any children of your spouse's who are from another marriage if applicable).
Child 1 name
date of birth (mm/dd/yyyy)
gender
country of birth
Passport no. (if applicable)
date of issue
country of issue
Current mailing address:
No. and street
City or Town
State or Province
Country
Zip Code or Pin Code
Child 2 name
date of birth (mm/dd/yyyy)
gender
country of birth
Passport no. (if applicable)
date of issue
country of issue
Current mailing address:
No. and street
City or Town
State or Province
Country
Zip Code or Pin Code
Child 3 name
date of birth (mm/dd/yyyy)
gender
country of birth
Passport no. (if applicable)
date of issue
country of issue
Current mailing address:
No. and street
City or Town
State or Province
Country
Zip Code or Pin Code
Child 4 name
date of birth (mm/dd/yyyy)
gender
country of birth
Passport no. (if applicable)
date of issue
country of issue
Current mailing address:
No. and street
City or Town
State or Province
Country
Zip Code or Pin Code
23. Information concerning your current passport (applicant):
Passport number:
Date of issue (mm/dd/yyyy):
Date of expiration:
Country of issue
24. Information concerning your spouse's current passport:
Passport number:
Date of issue (mm/dd/yyyy):
Date of expiration:
Country of issue
25. Have you ever taken the TOEFL, TWE, or TSE exams:
Yes
Mode
Scores: i. TOEFL
TWE
TSE
date taken (mm/dd/yyyy):
place taken:
registration number:
No
26. Have you ever taken the IELTS exam?
Yes
Module:
Scores: Speaking band
Overall band
date taken (mm/dd/yyyy):
place taken:
registration number:
No  
27. List all languages that you (applicant):
Speak
Read
Write
28. List all the US visas and/or Green Cards you have ever applied for: NOTE: You must list all visas and/or green cards applied for, including visas/green cards -denied, canceled, or status currently unknown!
Type of visa/green card
Place of issue
State
Country
Date of issue (mm/dd/yyyy) (if granted)
Dates of stay in the US (mm/dd/yyyy) (if granted)
29. Have you ever received a J visa? yes
no
30. Are you subject to the 2-year foreign residency requirement? yes
no
31. Have you ever been refused any US visa and or green card?
Yes Please explain.
No  
32. Have you ever been convicted or arrested for any crimes?
Yes Please explain.
No  
33. Please list all countries you have ever lived in for six months or longer (beginning with the country of birth):
Name of country/
Length of residency
34. Which country are you currently living in?
35. Do you have any plans to depart from this location in the next 4-6 months? yes
no
36. Please list any relatives in the US who are U.S. citizens or U.S. residents and where they live:
37. To the best of your knowledge, has any application for a U.S. visa and or green card (permanent resident visa/immigrant visa) ever been filed on your behalf?
Yes Please explain.
No  

ATTESTATION
I hereby certify that the foregoing information provided by this questionnaire
is true and correct to the best of my knowledge.
Yes No

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