Application for Registration Examination in Nova Scotia

I hereby make application for examination under the LPN Act (2006) respecting Registration of Practical Nurses

Please contact CLPNNS if a hard copy is required.

The below application is only to be completed by applicants that have been approved by CLPNNS to write the Canadian Practical Nurse Registration Examination (CPNRE).


Personal Information

First Name:

Middle Name(s):

Last Name:

Previous (e.g. Maiden) Name(s):

Your personal email address:

Date of Birth:

Phone Number: (Home)(Cell)

Secondary Phone Number: (Home)(Cell)


Educational Institution

Name of Institution:

Campus:

Date of Entrance to Program:

Date of Graduation:


Canadian Practical Nurse Registration Exam (CPNRE)

Did NSCC collect the CPNRE fee with your tuition: YesNo

(If NO, please call CLPNNS at 1-800-718-8517 to arrange exam payment)

Do you plan to write the next CPNRE? YesNo

Graduates must write and pass the CPNRE within two years of graduation from a practical nursing / nursing program.


Signature

Release of Information: Under the Personal Information Protection and Electronic Documents Act (PIPEDA), your contact information may be released by the College to third parties for research, surveys or educational purposes.

I understand that information on this application, or in my supporting documentation, which includes personal information that belongs to me, may be communicated to third parties (such as exam providers) for the purpose of determining and communicating my eligibility for a registration exam and I consent to Assessment Strategies Inc. disclosing such information to their parties solely for that purpose. Methods of transmission include, but are not limited to: verbal, written, and email communication of this information.

I certify that I am the person named above and that I understand notification of Pass/Fail results will be released to the educational institution for statistical purposes only.

e-Signature:

Date:

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