Nursing Registration Form

The following information from your NNAS application identifies you to the nursing regulatory body. The application process will produce a version for each jurisdiction where you have been registered.

Please ensure that the information is correct, and sign and date each copy of the form. You must provide a form to each jurisdiction to have completed and mailed directly to NNAS.

Part A: PERSONAL INFORMATION

NNAS ID number: 10865204 Application number: 98257

First/Given name Middle name Last/Family nameXharen Yukari Chen-Chu Somogod Dulin

• Your other names:

• Name registration/license was issued under: Xharen Yukari Chen-Chu S. Dulin

Mailing Address384 1/2 Portland Street Apt.203 Dartmouth, Nova Scotia B2Y 1K8Canada

• Date of birth: 01/11/1993

Other contact information

• Phone Number: 1 (902) 292-9743

• E-mail Address: xharen_13@yahoo.com

Name of schoolof nursing/nursing educational institution

Address of nursing school

Name of nursing/psychiatric nursing program

Program Start Date Program completion/graduation date

CENTRAL PHILIPPINE UNIVERSITY

Philippines

Bachelor of Science in Nursing

07/06/2010 13/04/2014

98257

• Name of (current) nursing jurisdiction, registering board or authority: PROFESSIONAL REGULATION COMMISSION

Address of Jurisdiction/Registering Board/Authority Philippines

I hereby give my consent to you to provide the information requested in Part B of this form related to my Nurse Registration directly to NNAS at the following address:

NNASP. O. Box 8658Philadelphia, PA 19101-8658USA

Your signature: _______________________________________ Current date: _______________________(Please sign your name) (DD-MM-YYYY format)

98257

Part B: NURSING EXAMINATION AND REGISTRATION INFORMATION (for official authority to complete)

Please provide the following information (in English) concerning the Nursing Examination of this nurse. Please mail a completed form directly to NNAS at the above address.

• Name of registrant: ____________________________________________________________________________

• Name of nursing registration/licensing examination: ________________________________________________(The complete and formal name of the nursing registration/licensing examination completed)

• Date when nurse successfully completed the examination: ___________________________________________(Date this nurse successfully completed the registration examination in DD-MM-YYYY format)

• Language of nursing examination: __________________________________________________________

• Examination result: - Choose _____ Pass or _____ Fail

• Number of examination attempts: _______________

• Was the nursing program recognized or approved in the jurisdiction in which it was completed as qualifying the applicant to practice in that jurisdiction as the same level of nurse: - Choose _____ Yes or _____ No. If No, please provide details: _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________

• This nursing program was officially recognized, approved or accredited by: _________________________________________________________________________________________________________________________

• Date program was approved or accredited:________________(DD-MM-YYYY format)

Please provide the following information concerning the Nursing Registration of this nurse.

• Title of registration/license: _______________________________________________________________

• Nurse registration/license number: _____________________

• Status of this nurse's registration/license: - Choose one response: ____ practicing, (active) ____ non-practicing, (inactive) ____ provisional or ____ other, (explain): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

98257

•

Date registration/license issued: ______________________________________

(Date the registration/license was issued by your jurisdiction for this nurse in DD-MM-YYYY format)

• Is this a lifetime practice registration/license: - Choose _____ Yes or _____ No

• Date registration/license expires or expired: (if applicable) _____________________(Date the registration/license issued by your jurisdiction for this nurse expires in DD- MM-YYYY format)

• The method by which nurse was registered: - Choose one response for the method by which this nurse was registered: _____ examination _____ endorsement or _____ other, (explain): _______________________________________________________________________________________________________________________________________________

• Is nurse eligible for registration/licensure in your jurisdiction: - Choose ____ Yes, or ____No If No, please provide details: ______________________________________________________________________________________________________________________________________________________________________________________________

Please provide the following information concerning the registration status/license conditions on the nursing registration of this nurse.

• Does registration/license of this nurse have any current conditions or limitations/restrictions: - Choose ____Yesor ____ No If Yes, please provide details: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

• Is this registrant currently the subject of an inquiry, investigation or a proceeding for conduct unbecoming, professional misconduct, incompetence or incapacity or any similar investigation or proceeding in relation tothe practice of nursing or another profession in any jurisdiction: Choose ____Yes, or ____ No If Yes, please provide details: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

• Does this registrant have any physical/mental condition, disorder and/or addiction impairing his/her ability to practice as a nurse, or another profession: - Choose ____ Yes or ____ No If Yes, please attach an explanation.

• Has this registrant ever been refused registration/licensure to practice as a nurse? - Choose ___ Yes, or ____ No If Yes, please attach an explanation.

• Has this registrant's registration/license ever been suspended, restricted, surrendered, revoked, or subject toindividual terms and conditions to practice as a nurse, or another profession in any jurisdiction: - Choose ___Yes, or ____No. If Yes, please attach an explanation.

(If yes to above) Did this registrant get his/her license back: - Choose ____ Yes or ____ No

(If yes to above) Date of reinstatement: ___________________(DD-MM-YYYY format)

98257

Part C: IDENTIFICATION OF OFFICIAL

Please provide the following information for the official authorized to provide the registration information on this nurse.

Authorized to Provide Registration Information

Your complete printed name: ________________________________________________________________

Your official title: __________________________________________________________________________

Your signature: _____________________________________________ Current date: _________________(DD-MM-YYYY format)

Your phone number: ______________________________ Alternate phone number: ____________________(Number in the format: 123-456-7890, with your country code) (Where you can be reached if necessary)

E-mail address: ___________________________________________________________________________

Web site address: _________________________________________________________________________

Current physical address of this organization

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Please place the official seal or stamp of this organization here.

Please mail this completed form and any documents directly to:

Mailing address By Courier

NNASP. O. Box 8658Philadelphia, PA 19101-8658USA

NNAS3600 Market Street, Suite 400Philadelphia, PA 19104-2651USA

98257

Revised August 2014

Nursing Registration Form

The following information from your NNAS application identifies you to the nursing regulatory body. The application process will produce a version for each jurisdiction where you have been registered.

Please ensure that the information is correct, and sign and date each copy of the form. You must provide a form to each jurisdiction to have completed and mailed directly to NNAS.

Part A: PERSONAL INFORMATION

NNAS ID number: 10865204 Application number: 98257

First/Given name Middle name Last/Family nameXharen Yukari Chen-Chu Somogod Dulin

• Your other names:

• Name registration/license was issued under: Xharen Yukari Chen-Chu S. Dulin

Mailing Address384 1/2 Portland Street Apt.203 Dartmouth, Nova Scotia B2Y 1K8Canada

• Date of birth: 01/11/1993

Other contact information

• Phone Number: 1 (902) 292-9743

• E-mail Address: xharen_13@yahoo.com

Name of schoolof nursing/nursing educational institution

Address of nursing school

Name of nursing/psychiatric nursing program

Program Start Date Program completion/graduation date

CENTRAL PHILIPPINE UNIVERSITY

Philippines

Bachelor of Science in Nursing

07/06/2010 13/04/2014

98257

• Name of (current) nursing jurisdiction, registering board or authority: PROFESSIONAL REGULATION COMMISSION

Address of Jurisdiction/Registering Board/Authority Philippines

I hereby give my consent to you to provide the information requested in Part B of this form related to my Nurse Registration directly to NNAS at the following address:

NNASP. O. Box 8658Philadelphia, PA 19101-8658USA

Your signature: _______________________________________ Current date: _______________________(Please sign your name) (DD-MM-YYYY format)

98257

Part B: NURSING EXAMINATION AND REGISTRATION INFORMATION (for official authority to complete)

Please provide the following information (in English) concerning the Nursing Examination of this nurse. Please mail a completed form directly to NNAS at the above address.

• Name of registrant: ____________________________________________________________________________

• Name of nursing registration/licensing examination: ________________________________________________(The complete and formal name of the nursing registration/licensing examination completed)

• Date when nurse successfully completed the examination: ___________________________________________(Date this nurse successfully completed the registration examination in DD-MM-YYYY format)

• Language of nursing examination: __________________________________________________________

• Examination result: - Choose _____ Pass or _____ Fail

• Number of examination attempts: _______________

• Was the nursing program recognized or approved in the jurisdiction in which it was completed as qualifying the applicant to practice in that jurisdiction as the same level of nurse: - Choose _____ Yes or _____ No. If No, please provide details: _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________

• This nursing program was officially recognized, approved or accredited by: _________________________________________________________________________________________________________________________

• Date program was approved or accredited:________________(DD-MM-YYYY format)

Please provide the following information concerning the Nursing Registration of this nurse.

• Title of registration/license: _______________________________________________________________

• Nurse registration/license number: _____________________

• Status of this nurse's registration/license: - Choose one response: ____ practicing, (active) ____ non-practicing, (inactive) ____ provisional or ____ other, (explain): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

98257

•

Date registration/license issued: ______________________________________

(Date the registration/license was issued by your jurisdiction for this nurse in DD-MM-YYYY format)

• Is this a lifetime practice registration/license: - Choose _____ Yes or _____ No

• Date registration/license expires or expired: (if applicable) _____________________(Date the registration/license issued by your jurisdiction for this nurse expires in DD- MM-YYYY format)

• The method by which nurse was registered: - Choose one response for the method by which this nurse was registered: _____ examination _____ endorsement or _____ other, (explain): _______________________________________________________________________________________________________________________________________________

• Is nurse eligible for registration/licensure in your jurisdiction: - Choose ____ Yes, or ____No If No, please provide details: ______________________________________________________________________________________________________________________________________________________________________________________________

Please provide the following information concerning the registration status/license conditions on the nursing registration of this nurse.

• Does registration/license of this nurse have any current conditions or limitations/restrictions: - Choose ____Yesor ____ No If Yes, please provide details: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

• Is this registrant currently the subject of an inquiry, investigation or a proceeding for conduct unbecoming, professional misconduct, incompetence or incapacity or any similar investigation or proceeding in relation tothe practice of nursing or another profession in any jurisdiction: Choose ____Yes, or ____ No If Yes, please provide details: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

• Does this registrant have any physical/mental condition, disorder and/or addiction impairing his/her ability to practice as a nurse, or another profession: - Choose ____ Yes or ____ No If Yes, please attach an explanation.

• Has this registrant ever been refused registration/licensure to practice as a nurse? - Choose ___ Yes, or ____ No If Yes, please attach an explanation.

• Has this registrant's registration/license ever been suspended, restricted, surrendered, revoked, or subject toindividual terms and conditions to practice as a nurse, or another profession in any jurisdiction: - Choose ___Yes, or ____No. If Yes, please attach an explanation.

(If yes to above) Did this registrant get his/her license back: - Choose ____ Yes or ____ No

(If yes to above) Date of reinstatement: ___________________(DD-MM-YYYY format)

98257

Part C: IDENTIFICATION OF OFFICIAL

Please provide the following information for the official authorized to provide the registration information on this nurse.

Authorized to Provide Registration Information

Your complete printed name: ________________________________________________________________

Your official title: __________________________________________________________________________

Your signature: _____________________________________________ Current date: _________________(DD-MM-YYYY format)

Your phone number: ______________________________ Alternate phone number: ____________________(Number in the format: 123-456-7890, with your country code) (Where you can be reached if necessary)

E-mail address: ___________________________________________________________________________

Web site address: _________________________________________________________________________

Current physical address of this organization

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Please place the official seal or stamp of this organization here.

Please mail this completed form and any documents directly to:

Mailing address By Courier

NNASP. O. Box 8658Philadelphia, PA 19101-8658USA

NNAS3600 Market Street, Suite 400Philadelphia, PA 19104-2651USA

98257

Revised August 2014