11620 - 168 Street, Edmonton, Alberta T5M 4A6 Telephone (780) 451-0043

Toll Free in Canada 1-800-252-9392 Website www.nurses.ab.ca e-mail carna@nurses.ab.ca

I. Documentation of Registered Nursing Experience/Practice

(More space provided on next page)
This section is to provide a description of your nursing work experience. Please enter the total hours of ALL
nursing practice hours for each employer. Include all employment after your initial registration after
graduation from your nursing program. CARNA will not accept hours/week reporting

Name
File #

Start and End Employer Name and Practice Focus ()

Dates: D/M/YR Complete Address
Name: Direct Care:  Admin*
______________ ________________________________  medical-surgical  Research*
Start Date  obstetrics  Educator*
Address:  pediatric *provide details:
______________  mental health/psychiatry
End Date ________________________________  community  other (specify):
 long term care _______________________
________________________________
Total Hours Job Title and Description of Unit
______________ ________________________________

________________________________

Start and End Employer Name and Practice Focus ()

Dates: D/M/YR Complete Address
Name: Direct Care:  Admin*
______________ ________________________________  medical-surgical  Research*
Start Date  obstetrics  Educator*
Address:  pediatric *provide details:
______________  mental health/psychiatry
End Date ________________________________  community  other (specify):
 long term care _______________________
________________________________
Total Hours Job Title and Description of Unit
______________ ________________________________

________________________________

Signature of Applicant Date

Page 1 of 2 Updated 16 November 2011

 11620 - 168 Street, Edmonton, Alberta T5M 4A6 Telephone (780) 451-0043
Toll Free in Canada 1-800-252-9392 Website www.nurses.ab.ca e-mail carna@nurses.ab.ca

Name
File #

Start and End Employer Name and Practice Focus ()

Dates: D/M/YR Complete Address
Name: Direct Care:  Admin*
______________ ________________________________  medical-surgical  Research*
Start Date  obstetrics  Educator*
Address:  pediatric *provide details:
______________  mental health/psychiatry
End Date ________________________________  community  other (specify):
 long term care _______________________
________________________________
Total Hours Job Title and Description of Unit
______________ ________________________________

________________________________

Start and End Employer Name and Practice Focus ()

Dates: D/M/YR Complete Address
Name: Direct Care:  Admin*
______________ ________________________________  medical-surgical  Research*
Start Date  obstetrics  Educator*
Address:  pediatric *provide details:
______________  mental health/psychiatry
End Date ________________________________  community  other (specify):
 long term care _______________________
________________________________
Total Hours Job Title and Description of Unit
______________ ________________________________

________________________________

Signature of Applicant Date

(Please copy this page if you require more space to list employers)

Page 2 of 2 Updated 16 November 2011