ASSOCIATION OF REGISTERED NURSES OF PRINCE EDWARD ISLAND

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1 ASSOCIATION OF REGISTERED NURSES OF PRINCE EDWARD ISLAND 53 Grafton Street, Charlottetown PE C1A 1K8 Canada Tel: Fax: APPLICATION FOR ASSEMENT OF ELIGIBLITY FOR REGISTRATION The following steps/procedures must be followed when applying for registration with the Association of Registered Nurses of Prince Edward Island (ARNPEI). PART I - Complete and return to ARNPEI at the above address with the non-refundable application fee of $500 in Canadian funds copy of birth certificate copy of change of name certificates e.g. marriage/divorce certificates copy of government-issued identification with your photo on it (such as a photocopy of your passport photo page). PART II - Forward to the nurse registering authority where you were originally registered, i.e. upon completion of your nursing education program, and request them to complete and return it directly to ARNPEI. PART III - Forward to the nurse registering body where you are currently registered (if different from Part II) and request them to complete and return it directly to ARNPEI. PART IV - Forward to your school of nursing and request them to complete and return it directly to ARNPEI. Applicants must have completed an approved nursing program that included both theoretical and clinical preparation in the following fields: medicine, surgery, obstetrics, psychiatry and pediatrics. When seeking a transcript of your academic records, ask your school of nursing to provide a breakdown of actual theory and clinical hours in the five areas listed above. Your application cannot be assessed without this level of hourly breakdown. ARNPEI requires that internationally educated nurses have their academic records evaluated by World Education Services (WES). ARNPEI requires a WES Course-by-Course evaluation report based on nursing program information and transcript. When you apply to WES, either online or by paper application, indicate that you want ARNPEI to receive a copy of your evaluation report. An explanation as to the WES evaluation process, requirements and costs can be found at PART V - Forward to your last employing agency(s) and request them to complete and return it directly to ARNPEI. You must have worked a minimum of 1125 hours of paid nursing employment within the previous five years or have graduated within the previous five years. PART VI - If your first language is not English, you must demonstrate competence in the English language in speaking, reading, writing and listening by arranging for ARNPEI to receive the official English language test scores report directly from the testing agency within six (6) weeks of the date ARNPEI receives your application. Test scores must be current (within the last two (2) years).

2 ENGLISH LANGUAGE PROFICIENCY TESTS Name of Test Minimum Passing Score Website IELTS (International English Language Testing System) Writing Speaking 7.5 Listening 8 Reading 7 Total Score 7.5 (TOEIC) Test of English for International Communication Writing 200 Speaking Listening 495 Reading CELBAN (Canadian English Language Benchmarks Assessment for Nurses) Total Score 930 Writing 7 Speaking 8 Listening 10 Reading 8 Total Score N/A PART VII - A criminal record check must be obtained from the police agency in each jurisdiction in which you have resided in the previous two years and from your country of origin. Criminal record checks must have been issued within the previous six months. Upon receipt of all of the above, we will notify you as to your eligibility to write the Canadian Registered Nurse Examination (CRNE).

3 Part I - To be completed by the applicant and returned to the Association of Registered Nurses of PEI. Name Surname Given Names Birth/Former Name(s) Address Telephone Date of Birth Country of Birth Gender Female Male School of Nursing & Location Course Started: Course Completed: Month/Year Month/Year Nursing Experience Since Graduation: (List three most recent employers) Name and Address of Employer Position Dates Have you ever had any conditions placed on your registration or had your license suspended, cancelled, revoked or terminated for reasons of incompetence or misconduct? Have you ever been disciplined by an employer or a registration or licensing authority? Have you ever written the Canadian Registered Nurse Examination (RN exam) for registration in another Canadian jurisdiction? If yes, explain Have you ever been required/asked by another regulatory body in Canada to complete a competence assessment? (e.g. a competence assessment of your knowledge, skills and abilities using tools such as observation, interviews and written tests)? Have you ever completed a competence assessment in another Canadian jurisdiction? If you answered yes, please arrange for a certified true copy of the following to be sent to ARNPEI from the regulatory body as applicable: all letters associated with the process; the assessment report, and transcripts of education completed to bridge the gaps identified in the assessment report.

4 By signing this application form: I authorize ARNPEI to carry out the procedures necessary for the assessment of my eligibility for registration. This includes making copies of my application documents for the purpose of assessment and/or contacting the institutions or authorities stated on this application to verify the authenticity of my documents and the information provided regarding the educational institutions, regulatory bodies, and employers listed in my application. I declare that all of the information I have provided on this form is complete and truthful. I understand that ARNPEI will immediately: 1. stop the assessment of my application and 2. that my application for assessment will be cancelled, registration will be refused, and I will be banned from applying to the ARNPEI in the future if: a. I have provided any inaccurate information or b. I have omitted required information; or c. the ARNPEI determines that any documents submitted during the application or assessment process have been altered, tampered with or forged. This applies to all documents received during the application process, including educational transcripts, verifications of registration and written correspondence. ARNPEI will not issue a refund and will retain all documents submitted with my application. I understand that in order to practice nursing in Prince Edward Island, I am required by law to hold a license with ARNPEI, before I commence employment, including any orientation. I understand that the Registrar may destroy the application and supporting documentation of an applicant if the applicant has not completed the application within two years of the date the applicant submitted to the Registrar the completed application form. I have read and understand the above and the information on this form and agree to the terms stated herein. Signature of Applicant Date FOR OFFICE USE ONLY Processing Fee Original Current Transcript Employment Record English ID CRC Reg No: Date: Endorsement Examination Signature of Coordinator of Regulatory Services: June 2011

5 Part II - Verification of Original Nurse Registration and Examination Scores Section A Applicant - Complete Section A and forward application to the registering/licensing authority who issued your ORIGINAL registration/licensure. Request they verify your status by completing Section B. Name Surname Given Names Birth/Former Names(s) Address School of Nursing & Location Year of Graduation Year registered in original jurisdiction Registration Number Signature Date Section B - To be completed by the registering/licensing authority issuing ORIGINAL registration/licensure and returned directly to the Association of Registered Nurses of Prince Edward Island at the address noted below. Acting on behalf of the Name of Original Registering Authority I do hereby certify that Surname Given Names Birth/Former Names Year of Birth is a graduate of School of Nursing Location Type of Program and that the nursing education program was an approved program at the time of completion. The original registration certificate/license as a general registered nurse was issued by this jurisdiction on Registration number Registration status Registration was obtained by examination endorsement Expiry date of registration Is/has this registration/license ever been suspended, had conditions imposed, revoked or under investigation? (If yes, please attach an explanation.) YES/NO If yes, has this registration/license been reinstated? YES/NO Registration/license exam Date written Number of writings Score results If an examination was written more than three times, please explain. SEAL Date Title Signature Name (Please Print) Association of Registered Nurses of Prince Edward Island 53 Grafton Street, Charlottetown, PEI C1A 1K8 Tel: (902) Fax: (902)

6 Part III - Verification of Current Nurse Registration Section A Applicant - Complete Section A and forward application to the registering/licensing authority who issued your CURRENT registration/licensure. Request they verify your status by completing Section B. Name Surname Given Names Birth/Former Names(s) Address School of Nursing & Location Year of Graduation Year registered in your jurisdiction Registration Number Signature Date Section B - To be completed by the registering/licensing authority issuing CURRENT registration/licensure and returned directly to the Association of Registered Nurses of Prince Edward Island at the address noted below. Acting on behalf of the Name of Registering Authority I do hereby certify that Surname Given Names Birth/Former Names Year of Birth a graduate of School of Nursing Location was issued a certificate of registration as a registered general nurse by this jurisdiction on Registration Number Registration status Registration was obtained by examination endorsement Expiry date of registration Is/has this registration/license ever been suspended, had conditions imposed, revoked or under investigation? (If yes, please attach an explanation.) YES/NO If yes, has this registration/license been reinstated? YES/NO SEAL Date Title Signature Name (Please Print) Association of Registered Nurses of Prince Edward Island 53 Grafton Street, Charlottetown, PEI C1A 1K8 Tel: (902) Fax: (902)

7 Part IV - Verification of Graduation from School of Nursing Section A - Applicant to complete Section A and forward to your school of nursing for completion of Section B. Your school is to mail this form directly to the Association of Registered Nurses of PEI. Name Surname Given Names Birth/Former Name(s) School of Nursing Year graduated Your school of nursing is also to mail your school transcripts directly to World Education Services, 45 Charles Street East, Suite 700, Toronto, Ontario Canada M4Y 1S2. Section B - To be completed by the Director, School of Nursing, and mailed directly to the Association of Registered Nurses of PEI at the address noted below. Kindly provide the requested information regarding the nursing program completed by the above named applicant. If the program was taken in a country where English is not the official language, please secure translations through the nursing association in your country, or a qualified translator. THIS CERTIFIES THAT Surname Given Names Birth/Former Name(s) (Underline name used when enrolled in school) born on was admitted to Name of School of Nursing in. The program commenced and was completed. City/Province/State/Country Month/Year Month/Year The language of instruction for both theory and clinical was. The length of the program was months and included theory and clinical courses at the general nursing level. CRITICAL INFORMATION: The table below MUST be completed, identifying the number of theory and clinical hours in the five (5) program areas. The application cannot be processed without this information. A good faith estimate will be accepted. Program Areas Total Theory Hours Total Clincial Hours* Medical/Surgical (including specialty areas) Obstetrical Nursing Pediatric Nursing Psychiatric Nursing *Clinical hours do not include simulated client situations in the lab, high fidelity computerized patients, models, or simulators. Clinical experience must be face to face contact with clients in various health care settings. Signature Position Print Name Date The applicant s official transcript must be forwarded from the school of nursing directly to World Education Services (WES). See Section A of this form. Seal of the school of nursing is to be imprinted on the transcript and on this form. S E A L Association of Registered Nurses of Prince Edward Island 53 Grafton Street, Charlottetown, PEI C1A 1K8 Tel: (902) Fax: (902)

8 Part V - Statement from Current/Most Recent Employer Section A Applicant: Complete Section A and forward form to your current/most recent employer requesting completion of Section B. Name: Surname Given Names Birth/Former Name(s) Employee #: Signature: Telephone #/ Address: Date: Section B EMPLOYER: The above named applicant is applying for registration and licensure with the Association of Registered Nurses of Prince Edward Island. Please complete the following statements in relation to the applicant's employment as a registered nurse. If you are aware of a professional, ethical and/or health problem(s) that would indicate a license should not be granted, please state it. Please return the completed form to the Association of Registered Nurses of Prince Edward Island at the address noted below. A response by mail or is acceptable. Thank you for your assistance. This is to verify that Name of Employee was employed by Name of Organization Mailing Address between and Employment Status: (indicate one) Full Time Part Time Position: Total Hours Practised: Eligible for Re-Hire (If No, please explain): General Performance/Comments/Concerns: Signature Name (please print) Date Telephone #/ address Title (please print) Association of Registered Nurses of Prince Edward Island 53 Grafton Street, Charlottetown PE C1A 1K8 Canada Telephone: Fax:

9 VISA/MASTERCARD PAYMENT AUTHORIZATION FORM Name as it appears on credit card Name as it appears on application if different than the name on the credit card Phone number where the card holder can be reached address Please indicate which fee you are paying for Please bill my VISA MASTERCARD in the amount of $ Card Number Expiry Date Signature Date Please note: The credit card information provided on this form will not be retained. Upon authorization of the payment request all credit card information will be destroyed

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