RN Bridging/Re-entry Application

First Name:

Middle Name:

Last Name:

Preferred Name:

Street:

City:

Province/Country:

Postal Code:

Home Phone:

Work Phone:

Cell Phone:

Email:

Date of Birth (M/D/Y):

Country of Origin:

Country of Study:

Name of Nursing School:

Graduation Year from Nursing School:

Graduation Month from Nursing School:

Highest Level of Nursing Education:

Years of Experience as a Registered Nurse:

Currently Employed as:

RN

LPN

CCA

Other

N/A

Name of Current Canadian Employer:

Briefly describe most recent nursing position:

For Newcomers to Canada:

Arrival Date in Canada (M/D/Y):

Temporary Resident:

Permanent Resident:

Canadian Citizen?

Immigration Status

Languages:

English First Language?

Yes

No

If English is not the first language, was a language proficency test completed?

Yes

No

N/A

If yes, name of language proficiency test:

Date of language proficiency test:

Please indicate course(s) you are applying for:

Professional Nursing in Canada

Professional Communication for Nurses

Pharmacology for Nurses

Medication Administration for IENs

Health Assessment

Skills Course

Clinical Course

Maternal-Infant Health Theory

Maternal-Infant Health Clinical

Child Health Theory

Child Health Clinical

Psychiatric-Mental Health Theory

Psychiatric-Mental Health Clinical

Documentation Module

Changes in Health and Therapeutic Interventions

Changes in Health and Therapeutic Interventions II

Have you ever been referred for or participated in a competence assessment and/or education for initial RN registration in Canada?

Yes

No

If yes, when and where?

Name of RN regulatory body you have applied for RN registration in Canada:

NSCN

CRNPEI

Have you been given permission by the RN regulatory body to write the NCLEX-RN?

Yes

No

Note: If you were referred for this education by a RN Regulatory Body (for example, the Nova Scotia College of Nursing) and have signed a Consent for Release of Information , then this completed application can be shared with the RN Regulatory Body.

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