Evidence of Language Proficiency ─

Experience Form
College of Nurses of Ontario Telephone: 416 928-0900
101 Davenport Rd., Toronto, ON M5R 3P1 Toll-free (Canada): 1 800 387-5526
www.cno.org Fax: 416 928-6507

IMPORTANT: The evidence you provide in this form will be used by the College of Nurses of Ontario (CNO)
to determine if the applicant can communicate and understand effectively as a nurse. You must have direct
knowledge and contact with the applicant through employment, volunteer or other experience and must
provide examples of how they demonstrate language proficiency in listening, reading, writing and speaking in
English or French, relevant to the last two years. Making a false or misleading representation or statement
could result in the cancellation of the application(s) for registration and/or any certificate of registration that
may be issued. CNO may contact the organization as a source to validate the information provided on this
form

Please review the Privacy Policy at www.cno.org/privacy to understand how your personal information
will be used.
How to complete this form:
Step 1: The applicant should complete section 1 and send the form directly to the
Employer/organization/contact. Note: Applicant should remember to fill out their name and
application number in the space provided at the bottom of each page.
Step 2: The employer should complete section 2.
Step 3: The employer should complete required information and prepare a separate letter of reference
following the instructions in section 3.
Step 4: The employer should mail the form and documents in a sealed letterhead envelope to CNO using
the mailing address provided at the top of this form.

1. APPLICANT’S INFORMATION
           
First name Last Name

           
Application number Date of Birth (yyyy-mm-dd)

As part of my application to become a nurse in Ontario, CNO is requesting that your organization provides information
about my employment that proves that I am proficient in the English or French language. I hereby give you (my
previous/present employer, organization or other sources) consent to provide any and all information in your possession
to CNO regarding my language proficiency and experience. This shall constitute your legal authority to provide the
information and any other information which CNO shall request which may, in any way, be relevant to my application.

     
Applicant’s signature Date (yyyy-mm-dd)

© College of Nurses of Ontario Evidence of Language Proficiency – Experience Form (2019-97) 1

Evidence of Language Proficiency ─
Experience Form

2. EMPLOYER/ORGANIZATION INFORMATION
           
Name of employer/organization/contact Telephone number (include country code):

           
Address City

           
Province/State Country

3. EVIDENCE INFORMATION
Provide evidence of employment, volunteer and other experience where English or French was the primary
language used in listening, reading, writing and speaking. The evidence must be current or have been
completed within the last two years.

           
Applicant’s position title Total number of hours worked

           
Start date (yyyy-mm-dd) End date or last shift worked: (yyyy-mm-dd)

The focus of the employment/volunteer work was: Nursing Non-Nursing

Nature of applicant’s experience with the organization: Employment Volunteer Other

Please attach the following:

1. Applicant’s job description, including role and responsibilities.
2. Letter of reference from a direct supervisor or manager who can provide an evaluation of, and examples
of how the applicant uses/used their language abilities in listening, reading, writing and speaking.

I confirm that the evidence attached to this form is accurate and relates to the applicant’s experience within
the past two years.

           
Name & Title (please print) Telephone number (include country code)

           
Signature & Date (yyyy/mm/dd) Email address

Applicant’s Name: __________________ Application Number ___________

© College of Nurses of Ontario Evidence of Language Proficiency – Experience Form (2019-97) 2