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Ministry of Health Department of Nursing P. O. Box 848 Abu Dhabi United Arab Emirates Telephone: 6117-301/302/312
1. PARTICULARS OF APPLICANT
Full Name
(As it appears in Passport)
First name
Middle name
Previous Name
(If different from above only)
Day /
Month /
Year
Gender
Male
Female
Single UAE
Other (Specify)
Day / Month / Year
Expiry date
2. CONTACT INFORMATION
C/O P.O. Box # Telephone Other Home: Fax: City: Office: Email address: Emirate: Mobile:
3. EDUCATIONAL AND PROFESSIONAL PREPARATION 3. 1. General Education I completed the following level of general education before entering nursing / midwifery training . Intermediate Level High School Level Tertiary Level
3.2 1.
Professional Qualifications :
____years ___/___ ___/___ ____months ____years ___/___ ___/___ ____months ____years ___/___ ___/___ ____months ____years ___/___ ___/___ ____months ____years ___/___ ___/___ ____months ____ years ___/___ ___/___
_____months
2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2.
3. EDUCATIONAL AND PROFESSIONAL PREPARATION 3.3. Continuing Education: Include in-service training of at least 2 weeks duration
1. 2. Name of Institution Address of Institution Course Title Date From Date To Duration DD/MM/YY DD/MM/YY (Weeks)
__/__/__
____weeks
__/__/__
__/__/__
Position Held
1. __/__ 2. 1. __/__ 2. 1. __/____ __/__ 2. 1. __/__ 2. 1. __/____ __/__ 2. 1. __/__ 2. __/__ __/__ __/__ __/__
5. NURSING / MIDWIFERY LICENSURE OR REGISTRATION: List all licenses / registration which you hold including any in the UAE
Type: RN / RM License No. Assistant nurse, etc Country Issuing Date of Issue (DD/MM/YY) Expiration Date (DD/MM/YY)
6. LANGUAGE PROFICIENCY:
Language Arabic English Other:(specify) Written Fluent Good Fair Fluent Spoken Good Fair