Home Telephone Number: Mobile Phone Number: Country of Birth: Nationality: National Insurance Number: Country of Domicile / Permanent Residence: Have you resided outside of the UK/EU/EEA in the last three years? Day:______ Month:__________ Date of first entry to the UK Year:______ Date of most recent to the UK Day:______ Month:__________ Applicants not born in the (apart from holidays) Year:______ United Kingdom only Date from which you have been Day:______ granted permanent residence in the Year:______ UK Ethnic Origin: (tick box) Gypsy or Traveller or Black British Caribbean – Black or Black British African – Other Black background Asian or Asian British Indian – Asian or Asian British Pakistani – Asian or Asian British Bangladeshi – Chinese Other Asian Background Mixed White and Black Caribbean – Mixed White and Black African – Mixed White and Asian – Mixed background Other Ethnic Background Arab Additional Needs (tick box) No known disability Two or more impairments and/or disabling medical conditions A specific learning difficulty such as dyslexia, dyspraxia or AD(H)D A social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease or epilepsy A mental health condition such as depression, schizophrenia or anxiety disorder A physical impairment or mobility issues such as difficulty in using arms or using a wheelchair or crutches Deaf or serious hearing impairment Blind or a serious visual impairment uncorrected by glasses A disability, impairment or medical condition that is not listed above SECTION 1b: Professional Details Regulatory Body for Nursing and Midwifery Council (NMC) Registration: Health and Care Professions Council (HCPC)
Home Telephone Number: Mobile Phone Number: Country of Birth: Nationality: National Insurance Number: Country of Domicile / Permanent Residence: Have you resided outside of the UK/EU/EEA in the last three years? Applicants not born in the United Kingdom only Date of first entry to the UK Day:______ Month:__________ Year:______ Date of most recent to the UK (apart from holidays) Day:______ Month:__________ Year:______ Date from which you have been granted permanent residence in the UK Day:______ Year:______ Ethnic Origin: (tick box) Gypsy or Traveller or Black British – Caribbean Black or Black British – African Other Black background Asian or Asian British – Indian Asian or Asian British – Pakistani Asian or Asian British – Bangladeshi Chinese Other Asian Background Mixed – White and Black Caribbean Mixed – White and Black African Mixed – White and Asian Mixed background Other Ethnic Background Arab Additional Needs (tick box) No known disability Two or more impairments and/or disabling medical conditions A specific learning difficulty such as dyslexia, dyspraxia or AD(H)D A social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease or epilepsy A mental health condition such as depression, schizophrenia or anxiety disorder A physical impairment or mobility issues such as difficulty in using arms or using a wheelchair or crutches Deaf or serious hearing impairment Blind or a serious visual impairment uncorrected by glasses A disability, impairment or medical condition that is not listed above SECTION 1b: Professional Details Regulatory Body for Registration: Nursing and Midwifery Council (NMC) Health and Care Professions Council (HCPC)
NMPApplicationFormSection1.docx