Register as a Nurse
Australian Citizen - Unconditional Nurse

Personal/Contact Details
Last/Family name:
First name:
Preferred name:
Date of Birth (not compulsory):
Gender:
female male
Telephone (home):
Telephone (work):
Telephone (mobile):
Fax:
Current Residential Address:
Email address:
Please indicate your preferred method of contact:
Tel (home)  Tel (work)  Tel (mobile)  Fax   Email
Qualification Details
Where did you undertake your primary qualification?
Primary qualification type (eg. Hospital based or which university):
Year of qualification:
Do you have a Drug Therapy Protocol?
Nursing Registration Type:
RN EEN EN
Are you currently working?
yes no
Work History
Where you have worked in the last 5 years?
Name of General Practice Suburb & State Date from Date to
Referees (you must have worked with these two people in the last 1-5 years):
Name Relationship (eg colleague, principal, etc) Contact numbers
Current state you are registered in:
Registration Number:
Registered until:
Any Restrictions/Conditions (must be disclosed if applicable):
Work Preferences
State you would like to work in:
City/Country area you would like to work in:
Do you have a current driver's license?
yes no
Have you undertaken health assessments?
yes no
Please indicate which of the following computer systems you are familiar with:
 Pracsoft
 MSS
 Medical Director
 Genie
 Word
 Excel
 Powerpoint

Other (please specify):
Desired status:
 Full Time
 Part Time
 Casual
Please indicate your weekly availability (24-hour time please):
Start
Finish
Mon
Tue
Wed
Thu
Fri
Sat
Sun
What year level are you?
When are you intending to start?
Referral
How did your hear about us?
If applicable, name of AGPR Rewards member: