return to practice application form

8/12/2019 Return to Practice Application Form

1/4Deakin University CRICOS Provider Code: 00113B

NO. & STREET

SUBURB

EMAIL

APPLICATION AND ENROLMENT

RETURN TO PRACTICE AND INITIAL REGISTRATION

(OVERSEAS NURSES)

PREVIOUS NAME

if applicable

TITLE SURNAME

gender M or f daTe of birTH

TEL (Hm) TEL (b)

TEL (M) fax

STATE

counTryposTcode

GIVEN NAMES

fee caTegory

basis forADMISSION

gender M& fcourse code H011

locaTion B MODE Type

correspondence caT.

applicaTionKeyed by

SECTION 2: POSTAL ADDRESS

STUDENT ID NUMBER

p mt m dk tt

SECTION 4: AHPRA LETTER

p h m aHpra t wth 1 .

SECTION 6: RECORD OF RESULTS AND PROOF OF COURSE COMPLETION

p h eh t t m.

SECTION 7: NURSING REGISTRATION/LICENCE

p h t.

SECTION 3: AUSTRALIAN PERMANENT RESIDENCY

p h at tt (t t z at).

SECTION 1: PERSONAL DETAILS OFFICE USE ONLYSECTION 1: PERSONAL DETAILS OFFICE USE ONLY - DSA AND FACULTY

SECTION 5: ENGLISH LANGUAGE PROFICIENCY (not applicable to return to practice students)

at mt mt eh .

Whh th w h :

an overall b pass in occupaTional englisH TesT oeT.

inTernaTional englisH language TesTing sysTeM ielTs acadeMic Module:a score of aT leasT 7 in all four coMponenTs of ielTs reading; lisTening;WriTing and speaKing WiTH an overall band score of aT leasT 7.

please indicaTeTEST DATE

please indicaTeTEST DATE

PROF QUAL

N U

offered noT offered

selecTion officerNAME

SIGNATURE

TelepHoneexTension

DATE

/ /

DATE

/ /



SECTION 11: FINAL CHECKLIST

u th hkt t tht h mt all th t . y m m t mt.

Tk h mt all t th m

Tk h mt all t mt

Tk h all t m

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Tk h mt th diisrTe t th t .

SECTION 8: TERTIARY EDUCATION

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m tt. i th t , tt m th t mt.

dk stt id lt mt

H mt rt t p/i rt (o n) ? y n

i , t th m th t. dt

SECTION 9: EDUCATIONAL HISTORY

QualificaTions year INSTITUTION counTry are docuMenTs

aTTacHed? (y/n)

SECTION 10: NURSING EXPERIENCE

i t m th h mm t .

eMployer yearfinisHed

year

STARTED

POSITION counTryfull-TiMe/

parT-TiMe



SECTION 12: DECLARATION

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m m t/ t th m t m .

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i t th sttt, r r th ut.

i t t h m t t diiccsrTe (dtmt it, i, cmt ch, s, rh

T e) cHessn (cmmwth Hh e stt st nm),

m sle (stt l etmt). f it tt i tht i m th t m t t m.

SECTION 13: UNIT DETAILS

doMesTic applicanTs please

direcT applicaTions To:

p dmt ut

sh n Mw

dk ut,

M bw cm

221 bw Hhw

bw v 3125

ph: +61 3 92517776

f: +61 2 92446159

dk ut p sttmt twww.deakin.edu.au/web-disclaimer

SIGNATURE

DATE

inTernaTional applicanTs

please direcT applicaTions To:

itt am ct

dk itt

dk u t,

M bw cm

221 bw Hhw,

bw. vt 3125

at

Jh dw ph: +61 3 9627 4877

f: + 61 3 9244 5094

http://www.deakin.edu.au/future-students/

international/apply-entry/index.php

ut Hnn021

ut m nursing pracTice in ausTralia

p

cT2 (M)

cm g g M WmWtt W p bw

c x d (d) e (e) x (o-m) 1

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x

ut Hnn026

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p

cT2 (M)


c x d (d) e (e) x (o-m) 1

ct t

x

ut Hnn025

ut m clinical pracTicuM

p

cT2 (M)


c x d (d) e (e) x (o-m) 2

ct t

x
http://http//www.deakin.edu.au/web-disclaimerhttp://www.deakin.edu.au/future-students/international/apply-entry/index.phphttp://www.deakin.edu.au/future-students/international/apply-entry/index.phphttp://www.deakin.edu.au/future-students/international/apply-entry/index.phphttp://www.deakin.edu.au/future-students/international/apply-entry/index.phphttp://http//www.deakin.edu.au/web-disclaimer



STATISTICS

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SIGNATURE DATE

i h tht th m t mt:

y mt t mt th t t .

Th t q th dtmt it, i, cmt ch, s, rh T e (diiccsrTe) t t s 19-70(1) th Hh

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