Application for Trans Tasman mutual recognition

as a Registered Nurse, Enrolled Nurse or Midwife

ATMR-04

ATMR-04

Section 18 of the Trans Tasman Mutual Recognition Act 1997

This form is to be used by applicants applying for registration as a Registered Nurse, Enrolled Nurse or Midwife in Australia under the Commonwealth Trans Tasman Mutual Recognition Act 1997. This application will not be considered unless it is complete and all supporting documentation has been provided. All supporting documentation must: be certied in accordance with the Australian Health Practitioner Regulation Agencys (AHPRA) guidelines; and be in English. If original documents are not in English, you must provide a certied copy of the original document and translation in accordance with AHPRAs guidelines.

COMPLETING YOUR APPLICATION Read all instructions Print clearly in BLOCK LETTERS using a black or blue pen Place X in ALL applicable boxes:

SECTION A: Personal details and identication

Note: The information items in this section of the application that are marked with an asterisk (*) will appear on the public register.

1. What is your name? * Mr

Mrs Miss Ms Dr Other

It is important that you refer to the Boards Registration Standards, codes and guidelines should you be registered as you will be required to meet these standards for practice. These documents can be found at www.nursingmidwiferyboard.gov.au
PRIVACY AND CONFIDENTIALITY The information collected in this form is authorised or required under the Trans Tasman Mutual Recognition Act for the purposes of determining an applicants eligibility for registration and to provide for the protection of the public by ensuring that only health practitioners who are suitable persons and qualied to practise in a competent and ethical manner are registered. Information supplied on this form may be provided to other persons and agencies for workforce planning, information management and communication, criminal history and identity checking and other purposes as specied by the National Law. The Nursing and Midwifery Board of Australia and the Australian Health Practitioner Regulation Agency (AHPRA) are committed to ensuring the privacy and condentiality of personal information held and will adhere to the National Privacy Principles under the Privacy Act 1988 (Cth) when collecting, using, disclosing, securing and providing access to private information.

* Family (legal) name

* First given name

* Middle given name(s)

Previous names and other names known by

Preferred name

* Sex

OFFICE USE ONLY

Effective as of: 1 July 2010 Page 1 of 6

2. What are your birth details?

Date of birth

5. What is your residential address?

No. Suburb State/ Territory Postcode Street

DD MM YYYY
Country of birth

Place/city of birth

6. Please read this before answering the following questions about your principal place of practice in Australia:
If you are not practising the profession, or will not predominantly practise the profession at one address, you must provide the address of your principal place of residence or the address of an employment agency if this is applicable.

State of birth (if within Australia)

* Languages spoken other than English (optional)

Is your residential address the same as your principal place of practice in Australia? Yes No 3. Please read this before answering the following questions about identication documents:
Site name

Go to the next question Provide your principal place of practice address below

You need to provide 100 points of proof of identity documents with this application. Details on the required proof of identity documents can be found at either: AHPRA website: www.ahpra.gov.au; or Your local state ofce

No. Suburb State/ Territory

Street

Postcode

7. Where do you want postal correspondence delivered to? Residential address Principal place of practice

Note: AHPRA has the right to request presentation of the original documents.

Does your proof of identity include your passport? No Yes

Go to the next question Provide details below
Passport type (e.g. private/government) Country of issue Passport number No. Suburb State/ Territory

Other (Provide your postal correspondence address below)

Street

Postcode

8. Your contact details

During business hours

4. Does your proof of identity include an Australian Licence? No Yes

Go to the next question

After hours Provide details below Drivers

State of issue Licence number

(
Mobile

Firearm

Email

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9. Would you like to receive your renewal communications electronically? Some communication will always be sent by post. No Yes
Go to Section B: Registration history Provide details below Send me SMS reminders when my registration is due for renewal Send my renewal notices to the email address nominated above

SECTION D: Qualication for the profession

12. What are the details of the qualication or other method on which your registration in New Zealand is based?

1 Primary qualication
Title of qualication

Name of institution (University/College/Examining Body)

SECTION B: Application type

10. What type of registration are you applying for? Please mark ALL options that are applicable to your application. General registration
Registered nurse (Div 1) Enrolled nurse (Div 2) Midwife Completion date Length of program Country

MM

YYYY

2 Additional qualication SECTION C: Registration history

11. Do you currently hold registration that gives you legal authority to carry on the occupation of nurse or midwife in New Zealand? Yes No
STOP

Title of qualication

Name of institution (University/College/Examining Body)

Go to the next question

Country

You are not eligible for Trans Tasman Mutual Recognition.

Completion date

Length of program

You MUST attach to your application evidence of legal authority to currently carry on the occupation of Registered Nurse, Enrolled Nurse or Midwife in New Zealand. This must include: your original Annual Practising Certicate; or a complete and accurate certied copy of your Annual Practising Certicate.

MM

YYYY

3 Additional qualication
Title of qualication

Name of institution (University/College/Examining Body)

Country

Completion date

Length of program

MM

YYYY

Attach a separate sheet if all your academic qualications do not t within the spaces provided.

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SECTION E: Notice
13. In New Zealand, Australia or overseas, are you subject to disciplinary proceedings or any preliminary investigations or action that might lead to disciplinary proceedings? No Yes
Go to the next question You MUST attach details of any disciplinary proceedings or any preliminary investigations or action to this application.

SECTION F: Obligations of registered health practitioners

Registered health practitioners must inform the Board of a change in their status in relation to the following matters within 7 days after becoming aware of that change: the practitioner is charged with an offence punishable by 12 months imprisonment or more the practitioner is convicted of or the subject of a nding of guilt for an offence punishable by imprisonment appropriate professional indemnity insurance arrangements are no longer in place in relation to the practitioners practice of the profession the practitioners right to practise at a hospital or another facility at which health services are provided is withdrawn or restricted because of the practitioners conduct, professional performance or health the practitioners billing privileges are withdrawn or restricted under the Medicare Australia Act 1973 of the Commonwealth because of the practitioners conduct, professional performance or health the practitioner has a restriction placed on their right to prescribe or supply pharmaceutical benets under the National Health Act 1953 the practitioners authority under law of a State or Territory to administer, obtain, possess, prescribe, sell, supply or use a scheduled medicine or class of scheduled medicines is cancelled or restricted a complaint is made about the practitioner to a Commonwealth, State or Territory entity having functions relating to professional services provided by health practitioners or the regulation of health practitioners, including, but are not limited to: overseas regulatory authorities Commonwealth departments that administer Medicare Australia; the provision of pharmaceutical, sickness and hospital scheme; payments by way of medical benets and payments for hospital services; and immigration State and Territory bodies responsible for health complaints, workers compensation and trafc accident investigation

14. In New Zealand, Australia or overseas, is your registration cancelled or currently suspended as the result of disciplinary action? No Yes
Go to the next question You MUST attach details of any registration suspension or cancellation to this application.

15. In New Zealand, Australia or overseas, are you personally prohibited from carrying on nursing or midwifery practice? No Yes
Go to the next question You MUST attach details of any prohibitions to this application.

16. In New Zealand, Australia or overseas, are you subject to any special conditions as a result of criminal, civil or disciplinary proceedings? No Yes
Go to the next question You MUST attach details of any special conditions to this application.

17. In New Zealand, Australia or overseas, are you subject to any special conditions in carrying on practice as a nurse or midwife? No Yes
Go to the next question You MUST attach details of any special conditions to this application.

the practitioners registration under the law of another country that provides for the registration of health practitioners is suspended or cancelled or made subject to a condition or another restriction.

18. Do you commit to have appropriate professional indemnity insurance arrangements in place for all practice undertaken during the registration period? Yes
Go to the next question For further information on requirements see the Boards Professional indemnity insurance standard.

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SECTION G: Payment

SECTION H: Consent and declaration

21. PLEASE READ AND MAKE SURE YOU UNDERSTAND THESE STATEMENTS BEFORE SIGNING:
I consent to the National Board and AHPRA making enquiries of, and exchanging information with, the authorities of any Australian State or Territory, or other country, regarding my practice as a health practitioner or otherwise regarding matters relevant to this application.

You are required to pay both an application and a registration fee.

See website for fees applying www.nursingmidwiferyboard.gov.au Refund rules The application fee is non-refundable. The Registration fee will be refunded if the application is not approved.
Application fee Registration fee PAYMENT AMOUNT

+ $

= $

I acknowledge that the National Board may validate documents provided in support of this application as evidence of my identity that failure to complete all relevant sections of this application and enclose all supporting documentation may result in this application not being accepted.

19. How are you paying your application and registration fee?
Note: Payments in foreign currency cannot be accepted.

Mark one box only Visa or Mastercard (credit or debit card)

Go to next question

I undertake to comply with all relevant legislation, National Board registration standards, codes and guidelines.

I declare

Cheque/Money order (payable to Australian Health Practitioner Regulation Agency )

Go to question 21 You MUST attach cheque or money order.

that the above statements, and the documents provided in support of this application, are true and correct, and that I am the person named in the attached documents.

I make this declaration in the knowledge that a false statement may amount to perjury. It is also a ground for the Board to refuse registration.

Cash/EFTPOS (only available if paying in person)

Go to question 21

20. Visa or Mastercard details

Amount payable

The application must be signed by the applicant in front of the Witness.

Printed name of applicant

$
Visa or Mastercard number Signature of applicant Date

DD
Expiry date

MM YYYY

MM Y Y
Cardholders name

Printed name of person who can witness a statutory declaration

Signature of Witness Cardholders signature

Date

DD

MM YYYY

Role or occupation of Witness

Address of Witness
No. Suburb State/ Territory Postcode Street

Page 5 of 6

SECTION I: Checklist
22. Have the following items been attached (if required)?
A certied photocopy of your passport Question 3 A certied photocopy of your licence Question 4 Original or certied copy of your Annual Practising Certicate Question 11 A separate sheet with additional qualications Question 12 Details of any disciplinary proceedings or any preliminary investigations or action Question 13 Details of any registration suspension or cancellations Question 14 Details of any prohibitions Question 15 Details of any special conditions Question 16 + 17

23. Have the associated fees been paid or attached?

Application fee Completed Visa or Mastercard details provided OR Cheque or money order attached Registration fee Completed Visa or Mastercard details provided OR Cheque or money order attached

You may lodge this form in two ways: 1. By mail GPO Box 9958 IN YOUR CAPITAL CITY 2. In person Refer to www.ahpra.gov.au for the location of the AHPRA ofce in your state

You may contact the Australia Health Practitioner Regulation Agency on 1300 419 495 or you can lodge an enquiry at www.ahpra.gov.au

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