QR Code is for CGFNS Internal Use Only

Nursing Practice/Employment Form

The following information identifies the applicant to the nursing organization/employer in the jurisdiction where the applicant
is or was employed in a nursing role over the past five (5) years (current year first). Ensure this information is correct, then sign
and date the form. Provide this form to the nursing organization/employer to be completed and sent directly to CGFNS by the
employer.

Part A: Personal Information

ID Number: CT-00099068 Order Number: APP-00036740,

First/Given Name: Claire Izamae Date of Birth: 04-13-1993
Middle Name: Noora Phone Number: 09177104876
Last/Family Name: Intia Email Address: cintia@gbox.adnu.edu.ph

Mailing Address:
Street Address 1: Zone 2 San Jose
Street Address 2:
Street Address 3:
City/Town: Bombon
Province/State/Territory: Camarines Sur
Postal Code/Zip Code: 4404
Country: Philippines

Name of the Facility or Organization where employed: Ateneo De Naga University

I, Claire Izamae Noora Intia, hereby give my consent to Ateneo De Naga University to provide the information requested in
PART B of this form related to my nursing employment with this organization, and to send this completed form directly to
CGFNS at the following address:

For Standard Mail: For Courier Mail:

CGFNS International, Inc. CGFNS International, Inc.
ATTN: CVS: NCNZ ATTN: CVS: NCNZ
P.O. Box 8658 3600 Market Street, Suite 400
Philadelphia, PA 19101-8658 Philadelphia, PA 19104-2651
United States United States

Applicant Signature:______________________________________________ Date Signed__________________________________________

If you have any questions, please contact CGFNS via phone at +1 267-845-4521 or use the Support option in your CGFNS
Applicant Portal.
THIS FORM IS VALID FOR THE BELOW PERSON AND EMPLOYER
Claire Izamae Noora Intia, Ateneo De Naga University
ORDER # APP-00036740,, Page 1
 Part B: Nursing Employment Information
To be completed by employer. Please provide the following information (in English) concerning the nursing
practice/employment of this applicant. Spell out all names fully (no initials or abbreviations). If this applicant has held more
than one role/position, please fill out additional forms for each role/position held.
Do not leave any fields blank; mark questions that are not applicable as N/A.

Name of the Employer: ___________________________________________________________________________________________

Applicant's name used during employment:______________________________________________________________________

Job title or position held by this applicant:?_______________________________________________________________________

(Provide the complete title of the job or the position held by this applicant)

Job Status (Choose One):

Full-time Part-time Casual/Per Diem
Other (Explain): _____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

Type of Practice Setting Area or Unit in which the applicant worked:

Clinical Practice Management Teaching/Education Evaluation/Policy Research
If clinical practice, please select the settings(s):
Medicine Surgery Pediatrics/Children Psychiatric/Mental Geriatrics
Health
Community Obstetrics General Other: _______________________________

Number of total nursing practice/employment hours per year for each of the last five (5) years (not hours per week), with Year
1 being the most recent calendar year worked (as applicable):

Year 1 (2021): _____________hrs. Year 2 (2020) : _____________hrs. Year 3 (2019):_____________hrs.

Year 4 (2018): _____________hrs. Year 5 (2017): _____________hrs. Year 6 (2016):_____________hrs.

Total hours: _____________

Date this applicant was licensed to practice in the jurisdiction of employment: _______________________(dd/mm/yyyy)

Date this applicant started employment: _______________________(dd/mm/yyyy)

If the applicant began employment with your organization prior to obtaining a license to practice in the jurisdiction of
employment, please explain:

_____________________________________________________________________________________________________________________________________

Is applicant still employed? Yes No

If No, date this applicant ended his/her last shift of employment: ______________________________(dd/mm/yyyy)

If No, , date this applicant ended employment: ______________________________(dd/mm/yyyy)

Employment Category/Type:

THIS FORM IS VALID FOR THE BELOW PERSON AND EMPLOYER

Claire Izamae Noora Intia, Ateneo De Naga University
ORDER # APP-00036740,, Page 2
 Registered Nurse
Other (Explain): _____________________________________________________________________________________________________

Part C: Identification of Official

To be completed by the official/supervisor authorized to provide this applicant's employment information. Please spell out all
names fully (no initials or abbreviations).

Official authorized to provide employment information

Printed name: _________________________________________ Official Title: ____________________________________________

Phone Number: _______________________________________ Alternate Phone Number: ____________________________________
(123-456-7890 format with country code)

Email Address: ________________________________________ Website Address: ______________________________________________

Current address of this organization:

Name:_______________________________________________________________________________________________________________________
Address 1:___________________________________________________________________________________________________________________
Address 2: __________________________________________________________________________________________________________________
P.O. Box:_____________________________________________________________________________________________________________________
City/Town:___________________________________________________________________________________________________________________
Province/State/Territory:____________________________________________________________________________________________________
Postal Code/Zip Code:______________________________________________________________________________________________________
Country:_____________________________________________________________________________________________________________________

By signing below, I certify all information is true and correct to the best of my knowledge and has been provided by the
appropriate official.

Official’s Signature: ______________________________________ Date Signed: _____________________________________(dd/mm/yyyy)

[Official signature and date signed, are required for this document to
be accepted.]

In the space to the left, place the official seal or stamp of this organization (if available).

Please mail this completed form with any additional documents, making sure to include your return address and your
organization stamp/seal (if available) on the outside envelope, to:
Postal Mailing Address By Courier

CGFNS International, Inc. CGFNS International, Inc.

ATTN: CVS-NCNZ ATTN: CVS-NCNZ
P.O. Box 8628 3600 Market Street, Suite 400
Philadelphia, PA 19101-8658 Philadelphia, PA 19104-2651
USA USA

If you have any questions, please contact CGFNS via phone at +1 267-845-4521.

THIS FORM IS VALID FOR THE BELOW PERSON AND EMPLOYER

Claire Izamae Noora Intia, Ateneo De Naga University
ORDER # APP-00036740,, Page 3