Application form

Before completing the application Form, please read the following notes.

Notes:

  • This form must be typed, and submitted as an original document, in English, with original signatures in all places specified.
  • A Curriculum Vitae of the applicant(s) should be attached
  • All forms and documents must be mailed to JNC. The required documents include:
  • Curriculum vitae form as attached.
  • Certified statement for each applicant.
  • Three reference letters.
  • Proof that support the data presented in Your C.V
  • The applicant's comprehensive scientific work should be dispatched electronically on a CD or DVD or USB Memory Stick, together with the documents and other required information as per the application form and submit to

Jordanian Nursing Council

Tel: (00962-6) 5818724-5814083, Fax: (00962-6) 5824193,

P.O.Box 53 Amman 11831 Jordan, Email: ,

1-APPLICANT’S PERSONAL DATA:

Name / (First Name) / (Middle Name(s) / (Family Name)
Preferred title / Mr. Mrs. / Ms.Miss / Dr. Other
Date of Birth / (Month/Day/Year) / Nationality / Official Language
Home Address / ______
(Street No) (City) (State/Province/Country)
______
(Post Code) (Country)
Mailing address if different from home address: / ______
(Street No) (City) (State/Province/Country)
______
(Post Code) (Country)
Home Phone: / Home/office Fax:
Mobile phone: / Email address:
Applicant’s Employment
(if applicable) / Name of Organization:
Address:
______
(Street No) (City) (State/Province/Country)
______
(Post Code) (Country)
Office Phone:
______
(Country Code/Area Code/Number) / Fax:
______
(Country Code/Area Code/Number)
Signature of individual applicant: / Signature
(Typed name) (Typed title) / Date

2-CERTIFIED STATEMENT

The application must be certified by National/State/Provincial Nursing Council (NNC) or National/State/Provincial Regulation Authority (NRA).

Name of the National/State/Provincial Council or National/State/Provincial Regulation Authority

Address

(Street) (City) (State/Province/Country)

(Post Code) (Country)

Phone number: Fax number:

(Country Code/Area Code/Number) (Country Code/Area Code/Number)

Website: Email address:

We hereby certify that Is a Registered Nurse (first level) or Registered Midwife and a current member of our NNC or NRA or is retired.

Signature of the President, Executive Director, or other duty authorized representative of the NNC or NRA.

Signature Date

(Typed name) (Typed title)

3-APPLICANT STATEMENT

Note: This form should be completed by each individual applicant.

State in concise terms the significant contribution or impact you have made, within the nursing and/or midwifery profession, and/or for the development of the nursing and or midwifery profession and quality of life and health of the people. One additional page can be added.

Name and Signature Date

4-PROFESSIONAL REFERENCES

Name of Applicant:______

Mr. Mrs Ms. Miss Dr. Other

1 / Name of Reference:
Position Title:
Organization/Company:
Email Address:
Telephone:
2 / Name of Reference:
Position Title:
Organization/Company:
Email Address:
Telephone:
3 / Name of Reference:
Position Title:
Organization/Company:
Email Address:
Telephone:

1