*ASGR-40*

Application for general registration

ASGR-40
for students completing an approved program of study Profession: Nursing and Midwifery
Part 7 Division 6 of the Health Practitioner Regulation National Law (the National Law)

This form is for students of Australian academic institutions who are completing their studies and who have never been registered or practised as a health practitioner in Australia or overseas. This is an application for general registration as a registered nurse, enrolled nurse or midwife in Australia. This application must be lodged, with all supporting documents, in the capital city of the state or territory where the approved program of study has been completed. It is important that you refer to the Boards registration guidelines before completing this application. Registration standards, codes and guidelines can be found at www.nursingmidwiferyboard.gov.au

Symbols in this form

Additional information Provides specific information about a question or section of the form. Attention Highlights important information about the form. Attach document(s) to this form Processing cannot occur until all required documents are received. Signature required Requests appropriate parties to sign the form where indicated. Mail document(s) directly to AHPRA Requires delivery of documents by an organisation or the applicant.

This application will not be considered unless it is complete and all supporting documentation has been provided. Supporting documentation must be certified in
accordance with the Australian Health Practitioner Regulation Agency (AHPRA) guidelines. For more information, see Certifying documents in the Information and definitions section of this form.

Completing this form

Read and complete all questions. Ensure that all pages and required attachments are returned to AHPRA. Use a black or blue pen only. Print clearly in B L O C K

Privacy and confidentiality

The information collected in this form is authorised or required under the National Law for the purposes of determining an applicants eligibility for registration. Information supplied in this form may be provided to other people or agencies as specified in the National Law. The Board and AHPRA are committed to ensuring the privacy and confidentiality 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. AHPRAs Privacy policy explains how your personal information will be stored, handled and used. This document can be accessed at www.ahpra.gov.au/privacy.aspx

L E T T E RS

Place X in all applicable boxes: If you are completing this application on a computer you must use either Adobe Acrobat or Adobe Reader (version 7 or above). DO NOT send original documents unless specified.

SECTION A: Application criteria

1. Are you a new graduate or are you currently completing your studies relating to this application?
You must be a student of an Australian academic institution. YES NO

You are not eligible to use this application form. To apply for general registration, complete application form AGEN-40, which can be found at www.nursingmidwiferyboard.gov.au. 2. Have you ever been registered YES or practised as a health practitioner in Australia or overseas? 3. What are you applying for general registration as? 4. At what academic institution are you completing your study?
NO

You are not eligible to use this application form. To apply for general registration, complete application form AGEN-40, which can be found at www.nursingmidwiferyboard.gov.au.

Mark all options applicable to your application Registered nurse Enrolled nurse Name of institution State/Territory NSW VIC

Midwife

QLD

SA

WA

NT

TAS

ACT

5. What is your student identification number?

Student identification number

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SECTION B: Personal details

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The information items in this section of the application marked with an asterisk (*) will appear on the public register. 6. What is your name?
If you have ever been formally known by another name, or you are providing documents in another name, you must attach proof of your name change. For more information see Change of name in the Information and definitions section of this form. Title* MR MRS MISS MS DR OTHER SPECIFY First given name*

Middle name(s)* Family name*

Previous names known by (e.g. maiden name)

7. What are your birth details?

Date of birth

D D / MM / Y Y Y Y
Country of birth City of birth State/Territory of birth (if within Australia) VIC NSW QLD SA Sex* MALE FEMALE

WA

NT

TAS

ACT

Languages spoken other than English (optional)*

SECTION C: Contact information

8. What is your residential address?
If you are not currently practising, or are not practising the profession predominantly at one address: your residential address will be recognised as your principal place of practice, and the information items marked will appear on the public register as your principal place of practice. Refer to the next question for the definition of principal place of practice. Residential address cannot be a PO Box. City/Suburb/Town Address (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET) Site/Building and/or position/department (if applicable)

State or territory (e.g. VIC, ACT)/International province Country (if other than Australia)

Postcode/ZIP

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9. Is the address of your principal place of practice the same as your residential address?
Principal place of practice for a registered health practitioner is: the address at which you predominantly practise the profession, or your principal place of residence, if you are not practising the profession or are not practising the profession predominantly at one address. Principal place of practice cannot be a PO Box. The information items marked with an asterisk (*) will appear on the public register.

YES

NO

Provide your Australian principal place of practice below

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Site/Building and/or position/department (if applicable)

Address (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET)

City/Suburb/Town*

State/Territory* (e.g. VIC, ACT)

Postcode*

10. What is your mailing address?

My residential address My principal place of practice Other (Provide your mailing address below) Site/Building and/or position/department (if applicable)

Address/PO Box (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET; or PO BOX 1234)

City/Suburb/Town

State or territory (e.g. VIC, ACT)/International province

Postcode/ZIP

Country (if other than Australia)

11. What are your contact details?

Provide your current contact details below place an Business hours After hours Email

next to your preferred contact phone number. Mobile

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SECTION D: Proof of identity

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Applicants must provide sufficient evidence of their identity. When answering the question below, follow these four simple steps: Step 1: You must mark the table below and provide evidence of one of the documents listed under Category A. Step 2: You must mark the table below and provide evidence of one of the documents listed under Category B. This document must be different to that provided in Step 1. Step 3: You must mark the table below and provide evidence of one of the documents listed under Category C. This document must be different to those provided in Steps 1 and 2 above. Step 4: If the documents you have provided in Steps 2 and 3 above do not provide evidence of your residential address, you must mark the table below and provide one of the documents listed under Category D. The AHPRA Proof of identity requirements document can be found on the AHPRA website at www.ahpra.gov.au/identity.aspx The minimum requirements for overseas applicants, or those who have recently arrived in Australia, can be found in this document under the heading What special circumstances apply to overseas applicants or applicants who have recently arrived in Australia?. 12. Which documents from each category will you provide for proof of identity?
The documents provided must meet the following criteria: t least one document must be A in the applicants current name. Y our category B document must have a recent photo. ll documents must be officially A translated into English. For documents translated in Australia, the translator must be accredited by NAATI see www.naati.com.au For documents translated overseas, see www.fit-ift.org for a list of authorities who provide certified translations. Please refer to Translating documents at www.ahpra.gov.au/translate. aspx for further information. A ustralian birth certificate extracts are not accepted. f using your passport, a certified I copy of the identity information page (the photo page) must be provided. A ll documents must be true certified or notarised copies of the original. See Certifying documents in the Information and definitions section of this form for more information. Choose proof of identity documents to submit: (A document may only be used once for any category)

Documents
Australian passport Overseas passport with Aust. visa Australian birth certificate Australian visa Australian Armed Services papers Travel documents with Aust. visa Australian citizenship certificate Australian driver licence Working with children check card Firearm or shooters licence Student ID card International driver licence Proof of age card Change of name certificate Australian marriage certificate Australian divorce papers Board registration certificate Bank acct. details credit or ATM card

Category used: A B C

Documents
Medicare card PAYG payment summary

Category used: A B C NA NA NA NA NA NA NA NA NA NA NA NA NA NA

NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Motor vehicle registration Financial institution statement Taxation assessment notice Health insurance card Pension card

Category D documents
A document from Category D is only required if your Category B or C document does not provide evidence of your residential address. I have used a Category B or C document that has my current residential address Mortgage papers Rate notices Lease or tenancy agreement Utility account Electoral enrolment card

You must attach a certified copy of all proof of identity documents that you check above.

SECTION E: Qualification for the profession

In accordance with section 52 of the National Law, to be eligible for general registration you must be qualified for general registration in the health profession. Section 53 of the National Law states that to be qualified you must hold either: (a) an approved qualification for the health profession; or (b) a qualification that the National Board considers to be substantially equivalent, or based on similar competencies to an approved qualification; or (c) a qualification, not referred to in (a) or (b), relevant to the health profession and have successfully completed an examination or other assessment required by the National Board for the purpose of general registration in the health profession; or. (d) a qualification, not referred to in (a) or (b), that under the National Law, or a corresponding prior Act, qualified you for general registration in the health profession and you were previously registered on the basis of holding that qualification. The Boards website contains information on approved qualifications accepted under point (a) above and examinations or assessments accepted under point (c) above.

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13. What are the details of your qualifications and examinations/assessments?

As a student completing studies at an Australian university you may not yet have your qualification conferred, and are therefore unable and not required to provide a copy of your degree with your application. Your application will be processed when the Board receives advice direct from the relevant university that you have met the requirements of the course and are entitled to the qualification. For more information see Certifying documents in the Information and definitions section of this form. Primary qualification and examinations/assessments Title of qualification Name of institution (University/College/Examining body) Country Start date Completion date Length of program

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MM / Y Y Y Y

MM / Y Y Y Y

If you have received your academic qualification you must attach a certified copy.

SECTION F: Suitability statements

Information required by the Board to assess your suitability for registration is detailed in the following questions. It is recommended that you provide as much information as possible to enable the Board to reach a timely and informed decision. Please note that registration is dependent on suitability as defined in the National Law, and the requirements set out in the Boards registration standards. Refer to www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx for further information. 14. Do you have any criminal history in Australia?
For more information, see Criminal history in the Information and definitions section of this form. YES NO

Provide a separate sheet with details of your criminal history in Australia and explanation of circumstances.
YES NO

15. Do you have any criminal history in another country?

For more information, see Criminal history in the Information and definitions section of this form.

Provide a separate sheet with details of your criminal history in another country and explanation of circumstances.

For more information, see Professional indemnity insurance in the Information and definitions section 16. Do you commit to have of this form. appropriate professional indemnity insurance NO YES arrangements in place for all practice undertaken during the registration period? For more information, see Impairment in the Information and definitions section of this form. 17. Do you have an impairment that detrimentally affects, or is likely to detrimentally affect, YES NO your capacity to practise the profession? You must attach to this application details of any impairments and how they are managed.

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SECTION G: English language skills requirements

For registered nurses and midwives: The completion of five years full-time equivalent education, taught and assessed in English, means five years full-time equivalent of either: tertiary and secondary, or tertiary and vocational, or combined tertiary, secondary and vocational education taught and assessed in English in any of the recognised countries listed below. These five years must include evidence of a minimum of two years full-time equivalent pre-registration program of study approved by the recognised nursing and/or midwifery body in any of the recognised countries.

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For enrolled nurses: The completion of five years full-time equivalent education, taught and assessed in English, means five years full-time equivalent of either: vocational and secondary, or vocational and tertiary, or combined vocational, secondary and tertiary education taught and assessed in English in any of the recognised countries listed below. These five years must include evidence of a minimum of one year full-time equivalent pre-registration program of study approved by the recognised nursing and/or midwifery body in any of the recognised countries.

18. Have you completed five years NO Go to the next question full-time equivalent education, YES Provide the following details regarding your education in English, then go to as outlined above, taught Section H: Consent and obligations and assessed in English, in Mark applicable countries, then complete table below one or more of the following Australia Republic of Ireland United States of America recognised countries?
Canada New Zealand South Africa United Kingdom
Highest secondary Time frame level; tertiary and/or Month and year vocational qualification (e.g. Secondary - Yr 12, Commenced Completed (MM/YYYY) (MM/YYYY) Tertiary - degree) Student status (F/T) (P/T) Recognised country (See above) Academic transcript Attached

Program name If program incomplete, include subjects completed in the program

Education institution Name and address

For each program, you must provide a certified copy of your Academic Transcript (AT) detailing all subjects completed. If your AT is not yet available, please provide a copy of either a Certificate of Attainment (CoA) / Statements of Attainment / Statements of Results or Result Notices (however described by your education provider). Please attach a separate sheet with any additional details that do not fit within the space provided above. 19. Which of the English language examinations have you successfully completed?
Pass results must be obtained in one sitting. Choose appropriate option International English Language Test System (IELTS) Academic module The Board requires an IELTS Academic module score of at least 7 in each of the four components (listening, reading, writing and speaking). Occupational English Test (OET) The Board requires completion and an overall pass in the OET, with grades A or B only in each of the four components (listening, reading, writing and speaking). Date of completion

20. On what date did you complete this examination?

Pass result must be obtained in one sitting.

D D / MM / Y Y Y Y
You must send a certified copy of your Board-approved English language test results to your AHPRA state office. For IELTS, this evidence must include the Test Report Form Number and show that you have taken the Academic test module. Where possible, AHPRA will verify your test results directly with the testing authority (for example, by secure internet login).
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21. Were your results from the above-mentioned English language examinations obtained in the past two years?

YES

NO

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You must attach evidence that you: have actively maintained continuous practice and/or employment as a registered nurse, enrolled nurse or midwife, using English as the primary language of practice, in one of the recognised countries listed in question 18, and/or have been continuously enrolled in a program of study taught and assessed in English and approved by the recognised nursing and/or midwifery regulatory body, in any of the recognised countries listed in question 18.

SECTION H: Consent and obligations

Before you sign and date this form: Make sure that you have answered all of the relevant questions correctly and read the statements below. An incomplete form may delay processing and you may be asked to complete a new form. For more information, see the Information and definitions section of this form.

I consent to the 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. I authorise the Board to obtain my criminal history in Australia and overseas. I understand that: a complete criminal history, including resolved and unresolved charges, spent convictions, and findings of guilt for which no conviction was recorded, will be released to the Board, and information will be extracted from this form and used for the purpose of criminal history checking. This information may be used by Australian police services for law enforcement purposes including the investigation of any outstanding criminal offences. I acknowledge that: the Board may validate documents provided in support of this application as evidence of my identity, and failure to complete all relevant sections of this application and enclose all supporting documentation may result in this application not being accepted. I undertake to comply with all relevant legislation and Board registration standards, codes, and guidelines. I declare that: the above statements, and the documents provided in support of this application, are true and correct, and I am the person named in the attached documents. I make this declaration in the knowledge that a false statement is grounds for the Board to refuse registration. I am aware that personal information I provide may be given to a third party for regulatory purposes, consistent with the National Law.
Name of applicant Date Signature of applicant

Consent

D D / MM / Y Y Y Y Obligations of registered health practitioners

SIGN HERE

A registered health practitioner, excluding registrants holding non-practising registration, must: undertake the continuing professional development required by an approved registration standard for the profession, and not practise the profession unless appropriate professional indemnity insurance arrangements are in force in relation to the practice of the profession. All registered health practitioners must inform the Board within seven days of becoming aware of an event or change in their status in relation to the following matters: the practitioner is charged with an offence punishable by 12 months imprisonment or more the practitioner is convicted of, or the subject of, a finding 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 Human Services (Medicare) Act 1973 (Cth) because of the practitioners conduct, professional performance or health the practitioner has a restriction placed on their right to prescribe or supply pharmaceutical benefits under the National Health Act 1953 (Cth) 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) (b) (c) (d) (e) the Chief Executive Medicare under the Human Services (Medicare) Act 1973 (Cth) an entity performing functions under the Health Insurance Act 1973 (Cth) the Secretary within the meaning of the National Health Act 1953 (Cth) the Secretary to the Department in which the Migration Act 1958 (Cth) is administered, and another Commonwealth, State or Territory entity having functions relating to professional services provided by health practitioners or the regulation of health practitioners.

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. All registered health practitioners must inform the Board, in writing and provide appropriate evidence, within 30 days of any change in relation to the following: the practitioners principal place of practice the practitioners correspondence address, or the practitioners name.
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SECTION I: Payment You are required to pay both an application fee and a registration fee. Application fee: Registration fee:

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$160.00
Item

$ INSERT

FEE

Amount payable:

$ INSERT
Rebate for NSW registrants*

FEE

Select the annual registration fee from the table below, depending on your principal place of practice.
Registration fee Registration fee for NSW registrants*

Your required payment is detailed below:

Registration fee

$160

$3

$157

*Applicants whose principal place of practice is New South Wales pay the registration fee less the rebate from the NSW Government.

Registration Period The annual registration period for the nursing and midwifery profession is between 1 June and 31 May. If your application is made between 31 March and 31 May this year, you will be registered until 31 May next year. Applicants must pay 100% of the stated fees at the time of submitting the application. Refund rules The application fee is non-refundable. The registration fee will be refunded if the application is not approved. 22. How are you paying your fees? Mark one box below only
Payment by cheque, money order or bank draft must be in Australian currency, drawn on an Australian bank. A receipt will be posted. Visa or MasterCard Complete credit/debit card payment slip below Cheque/Money order/Bank draft

You must attach cheque, money order or bank draft payable to the Australian Health Practitioner Regulation Agency. Please write your name and registration number on the back of the cheque, money order or bank draft.
Cash/EFTPOS (only available if paying in person)

Please post this form with payment and required attachments to:

AHPRA GPO Box 9958 IN YOUR CAPITAL CITY (refer below)

Sydney NSW 2001 Adelaide SA 5001 Canberra ACT 2601 Perth WA 6001

You may contact AHPRA on 1300 419 495 or you can lodge an enquiry at www.ahpra.gov.au
Melbourne VIC 3001 Hobart TAS 7001 Brisbane QLD 4001 Darwin NT 0801

Credit/Debit card payment slip please fill out

Select card option Visa MasterCard Visa or MasterCard number Expiry date Name on card Amount payable

$
Cardholders signature

MM / Y Y

SIGN HERE
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Attached

SECTION J: Checklist
Have the following items been attached or arranged, if required?
Additional documentation Question 6 Question 12 Question 13 Question 14 Question 15 Question 17 Question 18 Question 20 Question 21 Question 21 Payment Application fee Registration fee Evidence of a change of name Certified copies of all documents that provide sufficient evidence of your identity Certified copies of your relevant academic qualifications A separate sheet with an explanation of circumstances of your criminal history in Australia A separate sheet with an explanation of circumstances of your criminal history overseas A separate sheet with your impairment details Certified copy of your Academic Transcript or a certified copy of either a Certificate of Attainment (CoA)/Statements of Attainment/ Statements of Results or Result Notices (however described by your education provider) Evidence of the successful completion of an approved English language test Evidence that you have actively maintained continuous practice and/or employment as a registered nurse, enrolled nurse or midwife using, English as the primary language of practice Evidence that you have been continuously enrolled in a program of study taught and assessed in English and approved by the recognised nursing and/or midwifery regulatory body

Information and definitions

CERTIFYING DOCUMENTS
Copies of documents provided in support of an application or other purpose required by the National Law, must be certified as true copies of the original documents. Certified documents must: be initialled on every page by the authorised officer be annotated on the last page as appropriate e.g. I have sighted the original document and certify this to be a true copy of the original, and signed by the authorised officer, and list the name, date of certification, contact phone number, and position number (if relevant), and have the stamp or seal of the authorised officer (if relevant) applied. Certified copies will only be accepted in hard copy by mail or in person (not by fax, email, etc.). Photocopies of previously certified documents will not be accepted. For a list of people authorised to certify documents and for more information, AHPRAs guidelines for certifying documents can be found online at www.ahpra.gov.au/certify.aspx

ENGLISH LANGUAGE SKILLS

To be eligible for registration you must be able to provide evidence of English language skills that meet the Boards English language skills registration standard, which can be found at www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx

IMPAIRMENT

Impairment means a physical or mental impairment, disability, condition, or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect your capacity to practise the profession. The National Law requires you to declare any impairments at the time of application. If you have an impairment, you will need to provide details of the impairment and how it is managed.

PRACTICE

CHANGE OF NAME

You must attach to your application a certified copy of evidence of a change of name if: you have ever been formally known by another name(s), or any of the documentation you are providing in support of your application is in another name(s). Evidence could include a marriage certificate, decree nisi, deed poll, or Statutory Declaration (which must explain the reason for the discrepancy).

Practice means any role, whether remunerated or not, in which the individual uses their skills and knowledge as a nurse or midwife. Practice is not restricted to the provision of direct clinical care. It also includes working in a direct nonclinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services in the profession and/ or use their professional skills.

PROFESSIONAL INDEMNITY INSURANCE (PII)

CRIMINAL HISTORY

Criminal history is defined in the National Law as: every conviction of the person for an offence, in a participating jurisdiction or elsewhere, and whether before or after the commencement of this Law, every plea of guilty or finding of guilt by a court of the person for an offence, in a participating jurisdiction or elsewhere, and whether before or after the commencement of this Law and whether or not a conviction is recorded for the offence, and every charge made against the person for an offence, in a participating jurisdiction or elsewhere, and whether before or after the commencement of this Law. Under the National Law, spent convictions legislation does not apply to criminal history disclosure requirements. Therefore, you must disclose your complete criminal history as detailed above, irrespective of the time that has lapsed since the charge was laid or the guilty finding was made. The Board will decide whether a health practitioners criminal history is relevant by considering the factors outlined in the Boards Criminal history registration standard, found online at www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx
Effective from: 13 November 2012

Nurses and midwives must not practise their respective profession unless they are covered by appropriate PII arrangements as outlined in the Boards Professional indemnity insurance arrangements registration standard. Nurses and midwives can meet this requirement through employers insurance, private insurance cover, or insurance gained through membership of a professional or industrial organisation. It is the nurse or midwifes responsibility to understand the nature of the cover supplied under these three options. Exemption from PII requirements may apply to midwives practising private midwifery. The Board has approved Guidelines for Professional Indemnity Insurance Arrangements for Midwives to use in conjunction with the registration standard. For more information, view the full registration standard and the Boards guidelines for midwives online at www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx

SUPPORTING DOCUMENTATION

All supporting documentation must: be certified in accordance with AHPRA guidelines, and be in English. If original documents are not in English, you must provide a certified copy of the original document and translation in accordance with AHPRA guidelines. DO NOT send original documents unless specified.
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