RESTORATION FORM POST 1 JULY

Transcription

1 RESTORATION FORM POST 1 JULY This form must be completed if your name has been removed from the Register of Nurses and Midwives for non-payment of Annual Retention Fee(s) and you have not restored before 1 July in that calendar year. Read the following before completing this form It should take approximately working days to process this form, once it is completed correctly. Please ensure you: 1. Complete in BLOCK CAPITAL letters This table should assist you in completing all sections of this form. A B C D E This section must be completed by you You also need to sign and date it Read and sign the declaration Complete the question regarding work in other jursidictions Read and complete the explanation section Read and complete the compulsory questions F Complete Debit/Credit Card Mandate G Read the privacy notice, sign and date it Returning your form Check that you have returned all pages Check that there are no missing details You should send the form to: Registration Department, Nursing and Midwifery Board of Ireland (NMBI) 18/20 Carysfort Avenue, Blackrock, Co. Dublin. 1 Restoration Form

2 A This section MUST be completed by the applicant. NMBI PIN SURNAME (As per your NMBI Registration) FORENAME OF BIRTH D D M M Y Y Y Y Please note: If you have changed your surname, attach a certified copy of your passport, marriage certificate or Deed Poll. For more information on certified copies, visit ADDRESS LANDLINE MOBILE Please note: You must keep your contact details up-to-date. You can update your contact details online on the My Account section JOB TITLE (Example: Staff Nurse, CNM1, ANP Emergency etc.) PLACE OF EMPLOYMENT Hospital/institution/other where you are employed etc.) PRACTISING DIVISION (Example: General, Psychiatric, Midwifery etc.) Tick if you are unemployed 2 Restoration Form

3 B Declaration that you have not practiced I hereby declare that I have not engaged in the practice (to include clinical practice and nursing/midwifery management, education or research) of nursing/midwifery in Ireland at any time during the following period FROM TO D D M M Y Y Y Y (Exact dates must be provided) D D M M Y Y Y Y C Certificate of Good Standing/Certificate of Current Professional Status (CCPS) Please complete the following question regarding working in another jurisdiction. Have you worked in another jurisdiction since you have been removed from the Register? If yes, NMBI must receive a current, original, translated Certificate of Good Standing/Certificate of Current Professional Status (CCPS). 3 Restoration Form

4 D Explanation Section Please detail below why you did not restore to the Register before 1 July of the calendar year in which you were removed and why you should be restored. 4 Restoration Form

5 E Compulsory questions Questions 1-7 are about your practice as a nurse or midwife and refer to all countries, states or jurisdictions where you have practised. Questions 8 and 9 relate to whether or not criminal convictions and investigations have been taken against you in any country, state or jurisdiction. Please answer all questions below 1 Has your registration, renewal certification or licence to practice as a nurse or midwife ever been refused? 2 Has your registration or licence to practise ever been cancelled, suspended or removed for any reason? 3 Have you ever been convicted of any criminal offence? 9 Do you have any health problem which in any way restricts your ability to practise? 8 Do you know of any investigation pending against your registration certification or licence to practise? 7 Are there any special conditions or restrictions currently attached to your registration certification or licence to practise? 6 Have any conditions or restrictions ever been attached to your registration certification or licence to practise? 5 Have you ever had disciplinary action taken against your registration certification or licence to practise? 4 Are there any criminal investigations or charges pending against you? If you have answered yes to any of the above questions, you must attach a letter with a detailed explanation about why you have answered yes to the question(s). Please sign and date the letter also and remember to include your PIN. 5 Restoration Form

6 F The fee for Restoration is 250. Please deduct 250 Restoration Fee plus the Annual Retention Fee Total amount to be deducted. Please ensure your Debit/Credit Card is current and there are sufficient funds to meet the payment. NMBI PIN APPLICANT S NAME By signing this form, I authorise the Nursing and Midwifery Board of Ireland to deduct the appropriate fee from my Debit/Credit card CARD TYPE CARD NUMBER EXPIRY / CVV NUMBER (CVV Number is the three digit code on the back of the card in the top-right corner of the signature box as indicated below) CVV number CARD HOLDER NAME (as per card) (of card holder) For office use only: PIN Transaction No: 6 Restoration Form

7 G Please read the following Privacy Notice Nursing and Midwifery Board of Ireland of Carysfort Avenue, Blackrock, Co. Dublin, Ireland is a data controller for the purpose of the relevant data protection law including the General Data Protection Regulation. We collect personal data from you (including special categories of personal data) in accordance with our Privacy Notice. In particular, we use personal data: Where we need to comply with a legal or regulatory obligation including our obligations under the Nurses and Midwives Act 2011 (as may be amended or updated from time to time); For the purpose of the performance of a contract between us; and/or For the purpose of a task carried out in the exercise of our official functions including under the Nurses and Midwives Act 2011 (as may be amended or updated from time to time). Please click here for further details on how we use your personal data and the legal basis on which we process your personal data. Please address any questions, comments and requests regarding our data processing practices to DataProtection@nmbi.ie I declare I have read NMBI s Privacy Notice. 7 Restoration Form