First Name:

Last (Sir) Name:

Contact Number:
Email Address:
Country of Current Residence:

Education

Degree(s) Attained:
Date of Graduation (month/year):
Name of School of Nursing:
Country of Education:

Licensure

License #1 Type:
Country of Issue:
License Number:
Date of Issue:
Expiry:

License #2 Type: If Applicable (add additional if more than 2 licenses)

Country of Issue:
License Number:
Date of Issue:
Expiry:

NCLEX

Have you passed the NCLEX?

If you passed…
Date Passed (Month, day/year):
U.S. Board of Nursing:

English Proficiency

If you have passed an English exam: No

Name of exam:

Updated 08/13/19
Exam version (Academic, General or IBT):
Date of Exam (Month/day/year):
Listening Score:
Overall Score:
Reading score:
Speaking score:
Writing score:

Work History

List all employers (paid nursing experience only), starting with the most
recent.
List EACH unit worked separately below.

Total Years of RN experience:

Name of Current Hospital:

Country:
Hospital website:
Total Bed Capacity:
Patient Medical Data Entry Method: Paper Charting or Electronic? (If Electronic, please
give the name EMR that you use):

Current Unit Specialty:

Unit Bed Capacity:
Nurse to Patient Ratio:
Your Title:
Start Date (month/day/year):
End Date: (month/day/year):

Types of Cases Seen/Treated:

Previous Unit Specialty (add additional entries for multiple units):

Unit Bed Capacity:
Nurse to Patient Ratio:
Your Title:
Start Date (month/day/year):
End Date: (month/day/year):

Updated 08/13/19
Types of Cases Seen/Treated:

Previous Unit Specialty (add additional entries for multiple units):

Unit Bed Capacity:
Nurse to Patient Ratio:
Your Title:
Start Date (month/day/year):
End Date: (month/day/year):

Types of Cases Seen/Treated:

Name of Previous Hospital:

Country: Abu Dhabi
Total Bed Capacity:
Patient Medical Data Entry Method: Paper Charting or Electronic? (If Electronic, please
give the name EMR that you use):

Previous Unit Specialty (add additional entries for multiple units):

Unit Bed Capacity:
Nurse to Patient Ratio:
Your Title:
Start Date (month/day/year):
End Date: (month/day/year):

Types of Cases Seen/Treated:

Name of Previous Hospital:

Country: Dubai
Total Bed Capacity:
Patient Medical Data Entry Method: Paper Charting or Electronic? (If Electronic, please
give the name EMR that you use):

Previous Unit Specialty (add additional entries for multiple units):

Unit Bed Capacity:
Nurse to Patient Ratio:

Updated 08/13/19
Your Title:
Start Date (month/day/year):
End Date: (month/day/year):

Types of Cases Seen/Treated:

Gaps of Employment

If you have had a gap in employment lasting longer than 90 days, please list.
If more than one employment gap, please add additional entries.

Date of Employment Gap Start (month/day/year):

Date of Employment Gap End (month/day/year):
Reason for Employment Gap:

Certifications

Certification (add additional entries for multiple certs):

Date of Issue:
Date of Expiry:

Updated 08/13/19