Application Brunei Darussalam Practising Certificate
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REGISTRATION NO. (for office use only) - How to complete this application Privacy and Confidentiality o Read and complete all questions o Ensure that all pages and required attachments are returned to BMO o Use a BLUE pen only o Print clearly in BLOCK LETTERS o Place X in all applicable boxes: o The Nursing Board for Brunei (NBB) and Board Management Office (BMO) are committed to protecting personal information as private and confidential. SECTION A: Personal Details MR MRS MISS MS DR Other: Date and Country of Birth: - - Age: year Sex: Male Female Nationality: Passport No: Country of Issue: Brunei I/C No: Colour: Yellow Purple Green Marital Status: Single Married Divorced Widowed Race: Religion: SECTION B: Contact Information Provide your current contact details below and place an next to your preferred contact phone number Office/Business hours After hours What is your residential address? Residential address cannot be a PO Box. Ministry of Health Brunei Darussalam Title: Full name: What are your contact details? Mobile Mobile Email Boards Manag em ent Office What is your mailing address? Your mailing address is used for postal correspondence My residential address My principal place of practice Other (provide your mailing address below) Post Code FORM-B Application for renewal of Practising Certificate Post Code What is your principal place of practice? The address at which you predominantly practice the profession and it cannot be a PO Box. Telephone Facsimile Post Code Type of practice: Government Private - - Date of Commencement: Department (if Government): P a g e 1 | 2
Transcript of Application Brunei Darussalam Practising Certificate
REGISTRATION NO. (for office use only)
-
How to complete this application Privacy and Confidentiality o Read and complete all questionso Ensure that all pages and required attachments are
returned to BMOo Use a BLUE pen onlyo Print clearly in BLOCK LETTERSo Place X in all applicable boxes:
o The Nursing Board for Brunei (NBB) and BoardManagement Office (BMO) are committed to protectingpersonal information as private and confidential.
SECTION A: Personal Details
MR MRS MISS MS DR Other:
Date and Country of Birth:
- - Age: year Sex: Male Female
Nationality: Passport No: Country of Issue:
Brunei I/C No: Colour: Yellow Purple Green
Marital Status: Single Married Divorced Widowed Race: Religion:
SECTION B: Contact Information Provide your current contact details below and place an next to your preferred contact phone number Office/Business hours
After hours
What is your residential address? Residential address cannot be a PO Box.
Ministry of Health Brunei Darussalam
Title:
Full name:
What are your contact details?
Mobile
Mobile
Boards Manag ement Office
What is your mailing address? Your mailing address is used for postal correspondence
My residential address My principal place of practice
Other (provide your mailing address below)
Post Code
FORM-B
Application for renewal of Practising Certificate
Post Code
What is your principal place of practice? The address at which you predominantly practice the profession and it cannot be a PO Box.
Telephone Facsimile
Post Code
Type of practice: Government Private
- - Date of Commencement:
Department (if Government): P a g e 1 | 2
What are the details of your latest qualifications?Latest additional qualification obtained within one year of renewal of Practising Certificate
Title of qualification
Name of institution (University/College/Examining body)
Country
Commencementdate:
- - Completion date:
Type of practice: Government Private
Date of Commencement: - -
Department (if Government):
SECTION C: Additional Nursing/Midwifery Qualification
- -
SECTION D: Declaration and Signature of Applicant
o I hereby declare that to the best of my knowledge and belief the information provided above and the attached documents are trueand authentic.
o I acknowledge that the Nursing Board for Brunei reserves all rights to withhold and/or terminate my registration and/or take anyaction it deems fit if any of the above information or documents tendered is found subsequently to be false. I am also aware that itis a criminal offence to make any false statements, to provide any false information and or document(s) to NBB under Section 9 ofNurses Registration Act, Cap 140, punishable with a fine of B$6,000.00 and imprisonment for twelve (12) months. I alsounderstand and give my consent for NBB to make any enquiries or obtain any information and documents that it deemsappropriate to establish my fitness to practise.
o I also authorise NBB to release the data provided by me, to the other parties where the Registrar deems essential for the purposeof their official duties under current legislations.
Date:
-
SECTION E: For Office Use Only
Payment for renewal of Practicing Certificate
Amount: Receipt No.: Date:
Processed by:
B$25.00 - -
Renewal approved:
YES NO
YES NO
YES NO
1. Have you ever been or are you currently the subject of an inquiry or an investigation by anylicensing authority in Brunei Darussalam or other countries with regards to professional misconduct,clinical malpractice or negligence claim?2. Have you ever suffered or are you suffering from any physical or mental illness which impairs yourfitness to practise as a Registered Nurse / Assistant Nurse?
3. Have you ever been convicted in Brunei Darussalam or elsewhere of any offence?
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P a g e 2 | 2
Please hand in this form with paymentand required attachment to:
n b b s e p t 2 0 1 6
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Fee for late renewal of Practising Certificate
Amount:
Overdue by : Day
Remarks
Receipt No.: Date: - -
Renewal rejected:
and Stamp: Signature
Signature of applicant:
n b b s e p t 2 0 1 6
Secretariat Boards Management Office 2nd Floor, Ministry of Health
Commonwealth Drive Brunei Darussalam
Tel: +6732380170 / +6732381640 ext 7964
