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 I understand that if I have knowingly made false statements and omissions my application will be withdrawn.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.