VERIFICATION OF EDUCATION FORM

Part I: Applicant fill the information in this area and forward to the Education Program

NAME: _________________/_____________________/______________________/____________________

  First                    /           Middle (Father) /    Grandfather            /                          Last

Date of Birth: _______________________ Place of Birth: _______________________    

Address

Home Address: _______________________________________________________ 

                         _______________________________________________________

Work Address: _______________________________________________________ 

                         _______________________________________________________

Mailing Address:  _______________________________________________________________

                             P.O BOX                      City /Sate                   Zip code                Country

Home Phone: _________________________    Work Phone: _________________________

E-mail Address: _____________________________________________________________

Preferred way of contact:  _ _ _ Home address _ _ _ Work Address _ _ _ Mailing address

Education Program: _________________________________________________________

Name of Institution: _____________________________________________________________

Degree Earned: ________________________ Date of Completion: ______________________

I hereby authorize  _____________________________________ to release my educational data to the Jordanian Nursing Council

Application Signature: _________________________Date: ___________________

VERIFICATION OF EDUCATION FORM

I hereby make application for certification for specialization in nursing according to law number (74) for the year 2006-Certification of Nursing Professional Levels.

Category of area of specialization:

Diploma 

Master

Doctoral  

1. Name:

____________________/_____________________/_____________________/_____________________

              First             /    Middle (Father)      /       Grandfather          /                Last

2. Date of Birth: _______________________ Place of Birth: _______________________    

3. Citizenship:   

Jordanian: 

National Security Number:  _ _ _ _ _ _ _ _ _  

ID Number: _ _ _ _ _ _ _ _ _

Issue date: ____/____/________Expiration date: ____/____/________

                  dd   / mm / yyyy                                   dd  / mm / yyyy    

Non-Jordanian:

Passport Number:  _ _ _ _ _ _ _ _ _ _ _ _   Place of issue: _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _

                                                                                                     City        / Country

Issue date: ____/____/________Expiration date: ____/____/________

                  dd   / mm / yyyy                                   dd  / mm / yyyy    

4. Address

Home Address: _______________________________________________________ 

                         _______________________________________________________

Work Address: _______________________________________________________  

                         _______________________________________________________

Mailing Address:  _______________________________________________________________

                             P.O BOX                      City /Sate                   Zip code                Country

Home Phone: _________________________    Work Phone: _________________________

E-mail Address: _____________________________________________________________

Preferred way of contact:  _ _ _ Home address _ _ _ Work Address _ _ _ Mailing address

5. Nursing licensure:

  Status

active 

inactive

active 

inactive

active 

inactive

active 

inactive

6. Has disciplinary action ever been taken against your license?    YES _____   NO ______

     If yes explain: ………………………………………………………………………………………………

7. Is disciplinary action pending against your license?                    YES _____   NO ______

    If yes explain: …………………………………………………………………………………………………

8. Have you ever been convicted of a felony?                                 YES _____   NO ______

    If yes explain: …………………………………………………………………………………………………

9. Education preparation:               University                      Country         Year Earned           Major

10. Working experience: please, start from your recent employment 

11. Securely glue at tape in this square

a current 2”X 2” photograph of yourself alone.

Photograph must be recent, passport type photo,

clear, front view, full face without a hat or dark glasses.  

*Write your name and date of photograph taken.

*Please, provide an additional 3 photographs