NURSING CONSULTANCY SERVICES
1052/54 Christchurch Road, Bournemouth, DorsetBH7 6DS, United Kingdom
TEL/FAX: + 44 (0) 870 168 9573 / +44 (0) 870 262 6554
Email:
APPLICATION FORM FOR SUPERVISED PRACTICE
PERSONAL DETAILS:
TITLE: Mr/Miss/Mrs/Ms______
SURNAME______
FIRST NAMES ______
ADDRESS:______
______
______
______
______
______
EMAIL: ______
TEL/FAX: Home______
Work______
DATE OF BIRTH______
NATIONALITY ______
MARITAL STATUS______
EMPLOYMENT HISTORY
NAME AND ADDRESS OF EMPLOYER POSITION FROM TO
If you were offered a job in the UK – how soon would you be able to take it up?
Do you have a current Nursing licence (registration number)?
What is the PIN number?
What is the expiry date?
Are you registered with the NMC (formerly UKCC)? YES/NO
At what stage is your application?
If you are applying for NMC registration what is your application number?
If you have been previously rejected from the NMC (UKCC), what was the date?
SUPPORTING INFORMATION
Any additional information you may wish to tell us.
SIGNATURE AND DECLARATION
Have you ever been convicted of any criminal offence? YES/NO
If yes, give date(s)
I certify that the information I have given is complete and accurate. I understand that if I have knowingly made false statements and omissions my application will be withdrawn. I also abide by the terms and conditions which I have read and understood.
SIGNATURE OF APPLICANT
DATE
CONSULTANCY FEE
I am enclosing the first payment by International Money Orders/Banker’s Draft for £250made payable to: NURSING CONSULTANCY SERVICES.
I am paying in instalments and enclose the first instalment of £______. I abide to pay the rest of the consultancy fee. I understand that no documentation will be sent to me until I have paid in full. (delete as appropriate)
FOR OFFICE USE ONLY
Date Received Accepted
NMC Doc Fee Paid
Instalments Documentation sent
Accepted For Adaptation Entry to UK
Date to Start
Terms and Conditions:
1. NCSi will, within its remit, provide consultancy and will only accept responsibility for the outcome of applications if proper NCSI procedure is adhered to2. Clients of NCSi travelling to the UK will have to meet their own travelling and other expenses incurred 3. The once-only consultancy fee is non-refundable 4. The once-only consultancy fee is non-transferable5. Documents sent by NCSi are strictly confidential, and for clients of NCSi only. The contents of the consultancy pack must not be divulged to third parties. 6. For those paying in instalments no material will be sent until the consultancy fee has been paid in full 7. NCSi reserves the right to withdraw its services from clients who have not complied with its terms and conditions and with those who mislead NCSi either directly orindirectly 8. Telephone enquiries (where applicable) will be entertained from NCSI clients only and not from third parties to safeguard clients’ confidentiality 9. Applicants should allow up to 28 days for delivery of the consultancy pack, Applicants should notify its safe receipt. 10. The documents will be sent by international courier. In the event of non-delivery and the consignment returned back to us you will be charged £25 for the consignment to be re-sent to you. 11. NCSi is not an employment or a Recruitment/Placement agency and its sole remit is to provide consultancy through the complex maze of nurse training/adaptation/ONP application procedures throughout the world.