THE NURSING COUNCIL of TRINIDAD & TOBAGO The

Dolly-Hargreaves House, 5/26 Victoria

Square West, Port of Spain,Trinidad, Trinidad & Tobago, West Indies.

Processing Fees
Rec.#NA
Date: 15/03/2022

FORM OF STATEMENT as to TRAINING AND EXPERIENCE

SECTION I:
(To be completed in handwriting of Applicant;
I HEREBY SUBMIT the following particulars so that my eligibility for registration as a GENERAL NURSE may be assessed:-
NAME:COMAS CAMILLE
(Surname FIRST, IN BLOCK LETTERS)
Date of Birth:1979-12-26
of Marriage:0000-00-00
Nationality:Trinidad And Tobago
A: Particulars of BASIC EDUCATION (Give name of educational institutions, dates of attendance, Basic education Certificates/Diplomas to be submitted)
 Schoolname:-Florida Memorial University,Yearofpassing:-,subject:-Biology,Grade:-BSc
Schoolname:-Florida Memorial University,Yearofpassing:-,subject:-,Grade:-
Schoolname:-Florida Memorial University,Yearofpassing:-,subject:-,Grade:-
Schoolname:-Florida Memorial University,Yearofpassing:-,subject:-,Grade:-
Schoolname:-Florida Memorial University,Yearofpassing:-,subject:-,Grade:-
B: Particulars of NURSE TRAINING:
From :
To :
Name and Address of INSTITUTION OF TRAINING:-
type of Nurse Certificate gained (Certificate/Diploma/Degree,etc):
Date of registration as a NURSE in territory of Training:-
Registered NUMBER:-
NAME AND ADDRESS of REGISTERING NURSE BODY:-
C: Post-registration qualifications held in specialty or specialties as evidenced by certificate(s)/diploma(s),etc:-
Date
Date
Date
D: Particulars of EMPLOYMENT FOLLOWING Nurse Registration:-
From
To
SIGNATURE OF APPLICANT DATE
MAILING ADDRESS (Please print clearly):-
NOTE: The particulars requested of this Section are to be inserted by the Authority of the Applicants TRAINING INSTITUTION who will ensure that an
ORTGINAL TRANSCRIPT of TRAINING AND EXPERIENCE of the Applicant is attachfld. The Form and Transcript are then to be returned DIRECTLY
to the Office of the Nursing Council of Trinidad and Tobago by the Authority. Favms returned through Applicants may not be entertained.
SECTION II:
I. Name of TRAINING INSTITUTION OF APPLICANT
Address:
2. TOTAL BED CAPACITY of Training Institution = beds, comprising
Medical :-
 Surgical :-
Paediatric :-
Orthopaedic :-
Gynaecological :-
Obstetric :-
Any Other (state) *including eye, ear,nose and throat surgery)
If experiences of Applicant were received in affiliated institutions, please explain:-
3. Length of BASIC NURSING PROGRAMME offered by Training Institution:-
TOTAL expereiences stipulated by the Programme of Training:-
CLINICAL =
THEORETICAL =
Applicant COMMENCED Programme of Training on
Applicant COMPLETED Programme of Training on
Applicant passed the State/Province Registering Examination on:-
4. Experiences ACTUALLY RECEIVED by Applicant over period of Training:-
CLINICAL =
THEORETICAL =
Complete from records of the Training Institution, professional adjustment and deportment of Applicant:-
5. CERTIFICATE OF AUTHORITY:
(Give Official Title) of
(Training Institution)
DO CONFIRM that the Particulars entered on the reverse side of this document
by the Applicant with respect to his/her training and registration are TRUE AND CORRECT.
NAME OF AUTHORITY (Please print)
SIGNATURE of AUTHORITY
Mailing Address of Authority:-
DATE:15/03/2022
[ SEAL I or [ STAMP of [ AUTHORITY