Zimbabwe Nursing Application Form Template

Nursing Council Application
Zimbabwe, Africa / Operation of Hope Volunteer
Legal Name: First, Middle, Last
Before you fill out this form have the following on hand:
Today's Date: (Date format example June 2, 2021)

Last Name
Middle Name
First Name
I am registering as a
Previous Names Used (where applicable)
Email
example@example.com
Your Permanent Address
Street Address
Street Address Line 2
City/ ProvidenceState / Providence
Postal / Zip Code
Birthdate:
MonthDayYear
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Telephone
Please enter a valid phone number.Format: (000) 000-0000.
If applicable, document(s) that indicate NAME CHANGE from your CURRENT legal name as indicated on your nursing license. i.e.marriage license etc.
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Passport Information
Passport #
Nationality:
Passport Expiration Date: (Date format example June 2, 2021)
Passport Issued: (Date format example June 2, 2021)
Name as it Appears on your passport:
Upload CLEAR and readable picture of passport FACE PAGE. Name document as follows: LAST NAME_FIRST NAME_PASSPORT FACEPAGE
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Upload (1) one Official Passport Picture- NAME FILE as LAST NAME_FIRST NAME_PASSPORT PICTURE
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Do you have 6 Blank pages on your passport dated BEFORE and AFTER the mission dates?
COVID Vaccination (s)
COVID Vaccination(s) date (Date format example June 2, 2021)
COVID Vaccination Type- i.e. J&J, Moderna, etc.
Upload CLEAR and readable COVID CARD- ame document as follows: LAST NAME_FIRST NAME_COVID
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Nursing License(s)
Upload Certificate of "Good Standing" from link: https://www.nursys.com/LQC/LQCSearch.aspx
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Upload your CV/Resume Here- ame document as follows: LAST NAME_FIRST NAME_CV
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Certificate of Good Standing , and other certificates, if any i.e PALS, et- Name document as follows: LAST NAME_FIRST NAME_GGS or LAST NAME_FIRST NAME_PALS
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Upload photocopy of Clear and readable Nursing Diploma- LAST NAME_FIRST NAME_DIPLOMA
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Upload CLEAR and READABLE photocopies of Nursing Transcripts- LAST NAME_FIRST NAME_Transcripts
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Upload TWO letters of reference on Official letterhead- (1) must be from your current supervisor:- LAST NAME_FIRST NAME_Reference1 and LAST NAME_FIRST NAME_Reference2
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Marital Status

Professional Qualifications
Professional Qualifications
Rows Qualification Name of Training Institute Duration Awarded Date Awarded
1)
2)
3)
4)
Details of Internship(s) (where applicable)
Rows From To Discipline
Name and Place
Name and Place
Name and Place
Current License
Rows 1
Current Lic #
Country
State of Issue
Expiration Date
Current photocopy of current nursing license (Must not be expired BEFORE end of surgical mission) Name document as follows: LAST NAME_FIRST NAME_NURSING LIC
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Name of Current Employer:
Current Job Title:
Brief Job Description: (do not type "see resume")
Details of Present Employer: Contact Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Previous Employer:
Job Title:
Brief Job Description: (do not write "see resume"
Details of Present Employer: Contact Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Any other relevant information:
Post Graduate Experience/Employment
Please post all graduate employment/experience in reverse chronological order.
Dates From:
Dates To:
State of Issue:
Expiration Date: (Date format example June 2, 2021)

Rows	1
Current Lic #
Country
State of Issue
Expiration Date

I certify that the above information is correct. Date format example June 2, 2021
Name
First NameLast Name
You sign here:
Clear

Nurses Council of Zimbabwe Solemn Declaration
I, name current title of residential Street Address City State/ Province/ Country Zip and work Address Address Line 2 City State/ Provience/ Country Zip solemnly and sincerely declare as follows: That I am the person whose name appears on the certificate of the degree, diploma or other certificate on which I reply as a qualification for Nursing licensenursing lic # dated day, month, yearwhich was issued by me by the (name of nursing state) nursing state after having been truly examined by the said of Jennifer Trubenbach, CEO of Operation of Hope Worldwide.

Unless the certificate is in Latin or English, a certified translation in English must be attached.
That,
A. I have never been debarred from practice on the ground of professional misconduct;
B. My name has never been removed from any resident of members of my profession keep in accordance with the laws of the country in which I have practiced my profession;
C. No inquiry is pending which may result in my being debarred from practice on the grounds of the professional misconduct or the removal of my name from any register referred to in sub paragraph B

That the universities or training school at which the period during which I received my training are as follows:
Name of Institution name of institution Period of Training from day, month, year to day, month, year
Your Name
First NameLast Name
Jennifer Trubenbach's Signature declared before me
Clear
Jennifer Trubenbach Signed here on Month, Day, Year

Nurses Council of Zimbabwe
Certificate of Knowledge of English
This is to certify that I, Jennifer Trubenbach, CEO Operation of Hope have on this day, month and year interviewed blankof
Your Residential address
Street Address
Street Address Line 2
CityState / Province / Country
Postal / Zip Code
Your Business address
Street Address
Street Address Line 2
CityState / Province / Country
Postal / Zip Code
and a result thereof, I, Jennifer Trubenbach, California Notary, license # 2340462 expiration Dec 18, 2024 find their working knowledge of the English language is:

LEAVE THIS BLANK- Any remarks qualifying or amplifying the above statement and including a brief description of the manner in which the applicant knowledge of the English language was tested --- Applicant was tested verbally and in written form - Jennifer Trubenbach, CEO Operation of Hope

Signature of Jennifer Trubenbach, Attending Officer California Notary, license # 2340462 expiration Dec 18, 2024
Clear

DO NOT FILL BELOW- LEAVE BLANK
FOR OFFICIAL USE ONLY
For Official Use Only: Registration Number
For Official Use Only Conditional: If no: reasons:
Zimbabwe Nursing Council Date and Signature: (leave blank)
Should be Empty:

Rows	Qualification	Name of Training Institute	Duration Awarded	Date Awarded
1)
2)
3)
4)

Rows	From	To	Discipline
Name and Place
Name and Place
Name and Place

Nursing Council Application

Passport Information

COVID Vaccination (s)

Nursing License(s)

Professional Qualifications

Post Graduate Experience/Employment

Nurses Council of Zimbabwe Solemn Declaration

Nurses Council of Zimbabwe

DO NOT FILL BELOW- LEAVE BLANK