IPASS APPLICANT FORM FOR NCLEX AUSTRALIA

“Your International Exam Application Solution”

Kindly read the instructions carefully. Please complete the section below with details about
you. Information must be well filled in. Any missing information will be considered an
incomplete application and may cause a delay to your application.

This application is only intended for “REGISTERED NURSE” applicants. IPASS Processing is not
yet accepting applications for Midwife and Enrolled Nurse for Australia.

Filling up the application means that you consent that IPASS processing will process your
NCLEX-Australia application in your behalf. We respect your privacy and please be informed
that all information will be kept confidential.
1. Name as it appears on your UPDATED passport:
*First Name :
*Middle Name :
*Last Name :
Passport Number:
Date of Birth:
Gender:
Country of Birth:
Place/City of Birth
Current Contact Number:
(Local Australia Number: Number only with area code E.g 0312345678 or mobile E.g 0412345678
(International Number: Number only with plus (+) symbol E.g +63918888000)

2.Name as it appears on your degree: (If different from personal information section) :
Name as it appears on your Nursing Diploma: (First name/Middle name/ Last name)

(Foreign) Name as it appears on your Nursing License

*First name/ Middle name/ Last name:

3. If you are married, indicate your single/maiden 4. Facebook Username:

name
*First name :
*Middle name :
*Last name : 5. Birthdate:

6. Gender:
7. Nationality:

8. Email Address:
9. Current Residential Address: (House/Unit No., Floor & Bldg./ Street, Lot/ Blk, Brgy/Village)

IPASS PROCESSING UPDATED 01/2021

 *City/Municipality:
*Province/State:

*Zip Code:

Country:

10.Complete Permanent Mailing Address:

11. Name of you College/University:

*Complete schools’ address : (No., Street District/Town)

*Title of Qualification:
*Country You Obtained Your Qualification:

*Number of Years Attended :

*Month and Year Started :
*Month and Year Completed :
12. What profession or division of profession are you seeking register in? (RN, Enrolled Nurse,
Midwife)

13. Do you hold current registration as a registered nurse in New Zealand?:

14. Have you previously held general registration as a registered nurse in Australia?
15. Do you have other qualifications relevant to your profession as a registered nurse? (Yes/No) If
yes, what qualification do you have?

16. Do you hold a current APHRA “referral to board-approved bridging program” letter or referral to
OBA (outcome-based assessment) letter?
(You will hold one of these letters if you previously applied for registration as an IQNM but were
refused registration and referred to complete a bridging program or OBA).

17. Do you have other qualification relevant to your profession as a registered nurse?
18. Do you have an existing AHPRA account? If yes, please indicate your log in details:
Username:
Password:

19. Have you successfully passed the National Council Licensure Examination for Registered Nurse
(NCLEX-RN) within the past 10 years?

20. If you passed the NCLEX-RN within the past 10 years, do you have a NSCBN Candidate
Report/Pass Letter?

WORK EXPERIENCE:

IPASS PROCESSING UPDATED 01/2021

 21. Country you are currently working as a registered nurse?
22. State the entry and end date of your experience as a registered nurse?
Entry Date:
End Date:

23. Have you worked in other countries aside from the above stated country? If yes, kindly indicate
the entry dates and end dates of your work experience:
Country (1):
Entry Date:
End Date:

Country (2):
Entry Date:
End Date:

24. Are you working in a clinical area or a non-clinical area?

25. If you are working in a non-clinical area, what is your designation?

TARGET NCLEX Exam Date:

Please provide the following documents.

Make sure that the documents are CLEAR AND NOT CUT.

1. Colored scanned copy of NURSING DIPLOMA

2. Colored scanned copy of your UPDATED PASSPORT
3. Colored scanned copy of your Transcript of Records and Related Learning Experience

NOTE: All documents must be a certified true copy by a notary public. Please follow the
PROPER INSTRUCTION BY APHRA on how to have the certified true copy of the documents
required. Instructions will be provided by IPASS Processing after we have received this
applicant form.

IPASS PROCESSING UPDATED 01/2021