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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
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:
Mobile
Mobile
Email
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
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
- - Date of Commencement:
What are the details of your latest qualifications? Latest additional qualification obtained within one year of renewal of Practising Certificate
Title of qualification
Country
Date of Commencement: - -
Department (if Government):
- -
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 true and authentic.
o I acknowledge that the Nursing Board for Brunei reserves all rights to withhold and/or terminate my registration and/or take any action it deems fit if any of the above information or documents tendered is found subsequently to be false. I am also aware that it is a criminal offence to make any false statements, to provide any false information and or document(s) to NBB under Section 9 of Nurses Registration Act, Cap 140, punishable with a fine of B$6,000.00 and imprisonment for twelve (12) months. I also understand and give my consent for NBB to make any enquiries or obtain any information and documents that it deems appropriate 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 purpose of their official duties under current legislations.
Date:
Amount: Receipt No.: Date:
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 any licensing 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 your fitness to practise as a Registered Nurse / Assistant Nurse?
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Amount:
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
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Full name:
Country:
Commencement:
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Completion:
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Others: Off