ONLINE REGISTRATION FORM



Personal Particulars:
Title: Name:       Surname:
Identification Number:             Gender: Male Female
Date of Birth: / / Country of Birth: City of Birth:
Nationality:
Cell Number:            Home Number:    

Work Number:         Email:   
Residential Address:


Postal Address


Marital Status: Married     Single    Widow/Widower    Divorced
 
Educational Qualifications:
Highest Standard Passed:    School Attended:
Qualification: Year: Institution:
Did you do a pre-course in nursing? (If YES, please include copy of certificate)
Name of Course : Name of Institution
 
Knowledge of languages:
English:
Write: Good Fair None

Read: Good Fair None

Speak: Good Fair None
Other:
Write: Good Fair None

Read: Good Fair None

Speak: Good Fair None
 
Medical Fitness:
Mark each question with a X in the appropriate block
a. Do you suffer from any illness, sensory or physical disabilities? Yes No
   If YES, please specify
b. Have you ever experienced any back problems ? Yes No
   If YES, please specify condition and any treatment received
c. Have you ever sustained an occupational injury ? Yes No
   If YES, was it certified as such ?
   Did you receive any compensation for the injury ? Yes No
d. Are you pregnant ? Yes No
e. Do you smoke ? Yes No
 
References (People that you know)
Name of Reference: Telephone Numbers: Relationship (e.g girlfriend/relative):
 
DECLARATION:
I hereby declare that the above particulars are complete and correct:    Date: / /