APPLICATION FOR REGISTRATION / RE-REGISTRATION

AS A NURSE, MIDWIFE OR NURSE PRACTITIONER

APPLICATIONS WILL BE ACCEPTED ON THIS FORM ONLY

Applications will not be accepted by telephone, facsimile, or email

November 2008 ABN: 79 033 475 573

Postal address & Location: Office Hours:

Suite 1 Scala House 9 am – 4 pm Monday to Friday
11 Torrens Street (excluding public holidays)
BRADDON ACT 2612

Phone: + 61 2 6207 0413

This application form is for nurses or midwives who:
• are Australian Graduates who are not registered/enrolled elsewhere in Australia, or
• have previously been registered/enrolled in the ACT, and whose registration has lapsed within the last
five years and are not registered/enrolled elsewhere, and
are seeking registration or re-registration in the ACT under the Health Professionals Regulation 2004 as:
• a nurse under Schedule 3 section 3.5(1); or
• an enrolled nurse under Schedule 3 sections 3.5(3); or
• an enrolled nurse (medications) under Schedule 3 sections 3.7(3); or
• a nurse practitioner under Schedule 3 sections 3.7(1); or
• a midwife under Schedule 4 section 4.4.

If you have undertaken part of your studies outside of Australia or New Zealand, please contact the Board
before completing the application, as English language requirements may need to be met.

INSTRUCTIONS
• Print information clearly.
• Refer to the checklist on the last page before submitting the completed application form.
• Attach verified copies of the required documents to the application form as outlined in the checklist.
• If necessary, additional information can be provided on a separate sheet of paper, which should be signed,
dated and stapled to the application form.
NOTE:
• The Board will not assess any application submitted without payment.
• Incomplete applications cannot be processed, and will only be held for 6 months from the date the
application is received by the Board, and then destroyed. After this date, if registration is still required, a
new, complete application must be submitted.
• Applicants will be sent a receipt for payment, followed by a practicing card once registration has been
granted by the Board.
SHORT TERM REGISTRATION:
The Board meets monthly when applications are considered. If you require registration prior to the
next Board meeting, it may be possible to gain short-term registration. An additional fee of $30.00
applies. Please contact the Board staff if you need to discuss this option.

Integrity in Nursing and Midwifery

 APPLICATION FOR REGISTRATION / RE-REGISTRATION
AS A NURSE, MIDWIFE OR NURSE PRACTITIONER

1. TYPE OF REGISTRATION SOUGHT (Please tick the relevant boxes below).

[ ] Initial registration in the ACT

[ ] Re-registration in the ACT Previous Registration / Enrolment Number (if known): ……..……….
Note: In the ACT, a nurse cannot be both enrolled and registered.

[ ] Enrolled Nurse [ ] Enrolled Nurse - Authorised to administer medications

[ ] Registered Nurse [ ] Registered Nurse Practitioner
[ ] Midwife
2. SURNAME ________________________________TITLE ______________ (eg. Ms, Mrs, Mr, Prof, Dr, etc)
3. GIVEN NAMES ________________________________________________
4. DATE OF BIRTH Day ____ Month ____ Year______
5. GENDER Male / Female (Please circle one)
6. ALL PREVIOUS NAMES ________________________________________________
7. COUNTRY OF BIRTH ________________________
8. POSTAL ADDRESS
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Telephone No: ________________ Email: _____________________________ Mobile: __________________

9. WORK ADDRESS (if applicable)

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Telephone No: ________________ Email: _____________________________

Staple signed
passport sized
Insert a passport-sized photograph of the applicant’s head and shoulders, taken photograph
within the last year, signed by a person before whom a Statutory Declaration can be here.
made. DO NOT GLUE!

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 APPLICATION FOR REGISTRATION / RE-REGISTRATION
AS A NURSE, MIDWIFE OR NURSE PRACTITIONER

10. QUALIFICATION(S)
List nursing and / or midwifery qualifications and attach a verified copy of the Graduation Certificate/s OR a
verified copy of the Official Transcript of the nursing and / or midwifery education program/s which must indicate
that all components of the course have been successfully completed. Computer print-outs will not be accepted.

Qualification Educational Institution Length of study

From To

11. DETAILS OF EMPLOYMENT OVER THE LAST FIVE YEARS

List most recent employment first.

Name of employing State / Country Dates of employment Position

organisation
From……..To………

STATEMENT OF SERVICE
Provide a statement of service written on the employer’s official letterhead, from the most recent
employer(s) which includes the following information:
• Dates of employment;
• Position held;
• Name, signature and position of the person signing on behalf of the organisation.
OR
A professional reference from a Nurse Manager, Midwife Manager or immediate supervisor, written on the
employer’s official letterhead, dated and signed within the last five years, which includes the following
information:
• Dates of employment;
• A statement that the applicant meets the relevant Australian Nursing & Midwifery Council
Competency Standards within their area of practice as a nurse and /or midwife;
• Name, signature and position of the professional referee.

A professional reference is not required from applicants who are registering for the first time since
completing their qualification.

PRIVACY
From time to time the ACT Nursing and Midwifery Board sends out information that it considers to be of interest to its
registrants. Please tick this box [ ] if you do not want to receive material unrelated to your registration with the ACT
Nursing and Midwifery Board.
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Integrity in Nursing and Midwifery

 APPLICATION FOR REGISTRATION / RE-REGISTRATION
AS A NURSE, MIDWIFE OR NURSE PRACTITIONER

12. PROOF OF IDENTITY

Proof of identity is based upon a point system. For the purposes of this application, verified copies of proof of
identity, to the value of 100 points, are required to be attached to the application. Please indicate in the boxes
below, identification documents provided.
The minimum requirement is either a verified copy of your birth certificate or passport (worth 70 points each).
The remaining 30 points of identification can be made up from any of the following options:

[ ] Public service identification 40 points [ ] Social security card 40 points

[ ] Citizenship certificate 70 points [ ] Tertiary education identification 40 points

[ ] Drivers license 40 points [ ] Medicare Card 25 points

[ ] Credit Card 25 points

A passport-sized photograph of the applicant’s head and shoulders, taken within the last year, signed by a
person before whom a Statutory Declaration can be made, must also be included.
CHANGE OF NAME
A verified copy of the marriage certificate is required if the applicant has changed their family or last name
by marriage. If the applicant has been married more than once and had a change of name each time, a
verified copy of each marriage certificate is required.
If the applicant has a different first or last / family name or has an additional name to the names on the
birth / adoption / marriage certificate(s), evidence of changes in name must be provided. Required
documents may include verified copies of change of name certificate, deed poll or decree nisi.
In the event that the applicant has no substantive evidence of any change in name, or the names on the
identification differs from the name(s) on the current practicing certificate, a statutory declaration should
be completed and attached. Statutory Declaration forms may be obtained from Australia Post or from the
web site, http://www.ag.gov.au/www/agd/agd.nsf/Page/Statutory_declaration.
Important: If submitting a Statutory Declaration in support of a change in name, the Statutory Declaration
included in the application pack must also be completed.

Note: Registration will only be provided in the same names as are provided as proof of identification.
An original document can be verified as a true copy by any of the persons before whom a Statutory
Declaration may be made (see page 8 for the list). The person making the verification must write:
1. “This is a true copy of the original”;
2. their full name;
3. sign their name;
4. state their designated authority to verify the copy; and
5. write the date of verification

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Integrity in Nursing and Midwifery

 APPLICATION FOR REGISTRATION / RE-REGISTRATION
AS A NURSE, MIDWIFE OR NURSE PRACTITIONER

DECLARATION
To meet their legislative obligations relating to suitability to practice requirements, the Board has developed
the following declaration for nurses and midwives wishing to register in the ACT. Please tick the appropriate
response to each question listed below. Note that failure to respond to all questions will delay registration.

Name of applicant __________________________________________________________________________

1. Have you been refused registration / enrolment or has your registration / No [ ] Yes [ ]►
enrolment been suspended or cancelled in any other jurisdiction in Australia or Please provide a brief
any other country? explanation at Question 8
2. Have you had any restrictions or conditions placed on your registration/enrolment No [ ] Yes [ ]►
or are you under investigation in any other jurisdiction? Please provide a brief
explanation at Question 8
3. Have you had any criminal convictions or been found guilty of an offence? No [ ] Yes [ ]►
Please provide a brief
explanation at Question 8
4. Do you have an addiction to alcohol, another drug or another substance that may No [ ] Yes [ ]►
affect your ability to practise? Please provide a brief
explanation at Question 8
5. Are you mentally and physically FIT to practise? Yes [ ] No [ ]►
Please provide a brief
explanation at Question 8
6. If you are applying for registration as a nurse:
a. have you qualified or practised as a nurse in the last five years? Yes [ ] No [ ]►
Please provide a brief
explanation at Question 8
b. do you practice and meet the Australian Nursing and Midwifery (ANMC) Yes [ ] No [ ]►
competency standards for Nursing? Please provide a brief
explanation at Question 8
c. do you follow the ANMC Code of Professional Conduct and the Code of Yes [ ] No [ ]►
Ethics for Nurses? Please provide a brief
explanation at Question 8
7. If you are applying for registration as a midwife:
a. have you qualified or practised as a midwife in the last five years? Yes [ ] No [ ]►
Please provide a brief
explanation at Question 8
b. do you practice and meet the ANMC competency standards for Yes [ ] No [ ]►
Midwifery? Please provide a brief
explanation at Question 8
c. do you follow the Australia College of Midwives Inc (ACMI) Code of Ethics Yes [ ] No [ ]►
and Code of Practice for Midwives? Please provide a brief
explanation at Question 8

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Integrity in Nursing and Midwifery

 APPLICATION FOR REGISTRATION / RE-REGISTRATION
AS A NURSE, MIDWIFE OR NURSE PRACTITIONER

8. Additional Information – please use this space if you have been instructed to provide information relevant to questions 1 – 7.

If you need more space, attach an additional sheet

Question no.

Please contact the Board for assistance if you are not able to answer any of the questions above.
You are advised to make yourself aware of the Health Professionals ACT 2004 and the Health Professionals
Regulation 2004 located at www.legislation.act.gov.au; and the Australian Nursing and Midwifery Council
(ANMC) Competency Standards for nurses and midwives located at www.anmc.org.au.

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Integrity in Nursing and Midwifery

 APPLICATION FOR REGISTRATION / RE-REGISTRATION
AS A NURSE, MIDWIFE OR NURSE PRACTITIONER

STATUTORY DECLARATION
(1) I __________________________________________________________________________
Given Name/s Surname
(2) Of________________________________________________________________________________________
(3) Hereby do solemnly and sincerely declare that the previous statements, and documents submitted by me in
support of those statements are true and correct in every particular and that I am the person named in the
aforesaid statements.
(4) Further, I consent to the ACT Nursing and Midwifery Board making inquiries of, and the exchange of
information with, the authorities of any State or Territory Regulatory Authority regarding my activities in
practicing as a nurse and/or midwife or otherwise regarding matters relevant to the notice.
(5) I make this solemn declaration by virtue of the Statutory Declarations Act 1959, as amended and subject to
the penalties provided by this Act for making of false statements in statutory declarations, conscientiously
believing the statements contained in this declaration to be true in every particular.
I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of
an offence under section 11 of the Statutory Declarations Act 1959.

Signature of the person making the declaration ____________________________________________________

Declared at _____________________________________ this ______________ day of ________________ 20 _____

Before me,
(6) Name of person before
whom the declaration is made ________________________________________________
(7) Signature ________________________________________________

(8) The title of person

before whom the declaration is made ________________________________________________
Persons before whom a Statutory Declaration may be made:
Member of the Commonwealth Parliament, State Parliament, Legislative Assembly of the Australian Capital
Territory, Legislative Assembly of the Northern Territory, Legislative Assembly of Norfolk Island; Judge,
Magistrate, Master of a Court, Chief Executive Officer of a Federal Court, Registrar or Deputy Registrar of a
Court, Clerk of a Court, Clerk of Petty Sessions, Sheriff, Sheriff’s Officer, Bailiff, Barrister, Solicitor;
Registered Patent Attorney within the meaning of the Patents Act 1990, Justice of the Peace, Commissioner
for Affidavits, Notary Public, Commissioner for Declaration, Police Officer; Registered Medical Practitioner,
Registered Dentist, Registered Pharmacist, Registered Veterinary Surgeon, Minister of Religion designated as
an authorised marriage celebrant, Civil Marriage Celebrant, Holder of a Statutory Office, Alderman or
Councillor of a Municipal or Shire Council, Permanent Employee of the Commonwealth Government with 5
years service, Permanent Employee of a State Government with 5 years service, Permanent Employee of a
Territory Government with 5 years service, Permanent Employee of a Local Government with 5 years service,
Officer of the Australian Navy, the Australian Army, or the Australian Air Force within the meaning of the
Defence Force Discipline Act 1982, Non-Commissioned Officer within the meaning of the Defence Force
Discipline Act 1982 with 5 years service, Warrant Officer within the meaning of the Defence Force Discipline
Act 1982, Full-time Teacher at a School or Tertiary Education Institution, with 5 Years service, Registered
Nurse or Enrolled Nurse with 5 years service, Bank Manager, Bank Officer, Building Society Officer, Credit
Union Officer with 5 years service, Registered Member of the Institute of Chartered Accountants in Australia,
the Australian Society of Certified Practising Accountants or the National Institute of Accountants, Postal
Manager, Australian Postal Corporation Officer with 5 years service, Persons before whom a statutory
declaration may be made under the law of the State or Territory in which the declaration is made, Australian
Consular Officer or Australian Diplomatic Officer within the meaning of the Consular Fees Act 1985.

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Integrity in Nursing and Midwifery

 APPLICATION FOR REGISTRATION / RE-REGISTRATION
AS A NURSE, MIDWIFE OR NURSE PRACTITIONER

How will you pay your Cash/ EFTPOS [ ]► Counter only

registration fee of
$110? Cheque Money Order [ ]► Payable to ‘ACT Nursing and Midwifery Board’
The fee for registration
with short term Credit Card [ ]► Type of card Visa [ ] Mastercard [ ]
registration is $140
Card Number: ⎣ ⊥ ⊥ ⊥ ⎦ ⎣ ⊥ ⊥ ⊥ ⎦ ⎣ ⊥ ⊥ ⊥ ⎦ ⎣ ⊥ ⊥ ⊥ ⎦
Payment must be in
Australian Dollars. No Expiry Date: ____/____ Amount $_______
GST applies to this
payment Card Holder’s Name (Please print): _________________________________

Payments by Cash and Card Holder’s Signature: __________________________________________

EFTPOS can only be
made in person over the
counter

OFFICE USE ONLY

Date application received Processing Officer name Entered on database Fee paid Receipt issued
____ / ____ / ____ _____________________ Yes / No Yes / No Yes / No
Form complete Photograph Change of name Qualification Statement of Service
Yes / No Yes / No Yes / No Yes / No Yes / No
100 points of Restricted nurse / Name entered on mail exclusion list File recalled /
Identification midwife list checked created
Yes / No Yes / No Yes / No Yes / No

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Integrity in Nursing and Midwifery

 CHECKLIST FOR APPLICANT

BEFORE SUBMITTING YOUR APPLICATION, HAVE YOU ATTACHED THE FOLLOWING:

Cheque / money order in Australian dollars, and made payable to the ACT Nursing and Midwifery Board [ ]
Applications submitted without the required fee will be returned to the applicant

Completed application form [ ]

Completed declaration form on page 5 [ ]
Signed and witnessed Statutory Declaration on page 7 [ ]
Verified copies of proof of identity [ ]
Verified copies of evidence of all name changes [ ]
English Language Test results from the testing centre (If applicable) [ ]
Date requested:______________________

Signed passport sized photograph taken within the last year [ ]

100 points of identification (refer to part “Proof of Identity” section of the application form) [ ]
Verified copy of qualification or transcript of nursing and / or midwifery education program [ ]
Statement of service or a professional reference [ ]
(Not required from applicants who are registering for the first time since completing their qualification.)

DOCUMENTS TO BE SENT DIRECTLY TO THE ACT NURSING AND MIDWIFERY BOARD FROM THE APPROPRIATE
AUTHORITY

English Language Test results from the testing centre (If applicable) [ ]
Date requested:______________________

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 APPLICATION PROCESS

REGISTRATION CATEGORIES WITHIN THE ACT

The ACT Nursing and Midwifery Board recognises the following qualifications:
y Registered Nurse (RN)
y Registered Midwife (RM)
y Enrolled Nurse (EN)

SPECIALIST REGISTRATION CATEGORIES WITHIN THE ACT

The ACT Nursing and Midwifery Board recognises the following specialist
qualifications
y Registered Nurse - Nurse Practitioner
y Enrolled Nurse - Authorised to administer medications

Step 1 Step 4

INCLUDE PAYMENT
OBTAIN AN APPLICATION FORM
The Board accepts payment by the following methods:
Obtain the appropriate application form from the ACT Nursing and
™ Cheque or Money Order payable to the ACT Nursing and
Midwifery Board website at actnmb.act.gov.au
Midwifery Board
™ Obtain an “application for registration or re-registration” form if
™ Credit card (Bankcard, MasterCard or Visa only)
registering in the ACT for the first time as:
™ If paying by credit card, check that the correct expiry date is
y an enrolled nurse;
included on the application form
y a registered nurse; or
™ Cash (Australian dollars only) paid over the counter
y a midwife.
™ EFTPOS (no cash out facility) paid over the counter
™ Obtain an “application to add a nursing qualification” if already:
y Registered in the ACT as a registered nurse and you are
adding the qualification as Nurse Practitioner;
y Enrolled in the ACT as an Enrolled Nurse and you are
adding the qualification as an enrolled nurse authorised to
administer medications. Step 5

SUBMIT COMPLETED APPLICATION FORM (with all

attachments) TO THE BOARD
Step 2
Suite 1 Scala House, 11 Torrens Street,
BRADDON ACT 2612

COMPLETE THE APPLICATION FORM

Answer all sections of the application accurately, ensuring that you:
™ Provide a contact phone number
™ Include the length of study and year completed
™ Provide payment / payment details
™ Sign the Statutory Declaration and have your signature
witnessed by an authorised person as listed on the Statutory
Declaration
Note: Where the declaration indicated a question relating to recency
of practice, graduates of all nursing and / or midwifery education
programs can declare yes to this question because they have
undertaken clinical work within their program of education
Step 3
Step 6
ISSUING OF CERTIFICATE OF REGISTRATION & PRACTICING
CERTIFICATE
™ After submission, all completed applications will be forwarded
to the next available Board meeting.
™ NOTE - The Board meets on the 1st Friday of each month from
February - December - Check the web site for application close
dates
™ The Board will then issue a letter of registration and an annual
practicing certificate.
™ Alternatively if registration is required prior to the next Board
meeting, short term registration can be issued for an additional
fee.

PROVIDE CERTIFIED COPIES OF SUPPORTING DOCUMENTS New graduates should be aware that short term registration in the
AND ATTACH TO APPLICATION FORM ACT is not accepted by other states / territories for immediate
Include appropriate attachments with the application, as indicated on registration under the Mutual Recognition Act. Therefore, full
the application form registration needs to be approved by the ACT Board if you are
planning to undertake a New Graduate Program in another State or
the Northern Territory.

Integrity in Nursing and Midwifery