Application For Restoration - South African Nursing Council
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4South African Nursing Council
APPLICATION FOR RESTORATION
PERSONAL DETAILS
(If your surname has changed by marriage, a certified copy
of your marriage certificate must be submitted.)
S A Nursing Council reference number
Surname
Postal address
Given names in full
Maiden name (if applicable)
(year / month / day)
Date of birth
/
/
(Unless otherwise indicated, your address in the SANC register
will be changed to the above address)
Identity number
RESTORATION
(year/month/day)
Date on which you wish to be
PLEASE NOTE:
/
/
restored
IMMEDIATELY
Fill in EITHER the date on which you are going to
assume duty OR place a cross in the box marked
Name of employer/
“IMMEDIATELY”. In either case, you will not be
prospective employer (if applicable)
restored on a date earlier than the date on which the
Address of employer/
S A Nursing Council receives your completed
application form and the full amount payable. If you
prospective employer (if applicable)
mark “IMMEDIATELY” it means with effect from the
date on which you meet all the requirements and
NOT “while you wait”.
RESTORATION(S) FOR WHICH APPLICATION IS MADE (QUALIFICATIONS)
Mark the applicable block(s) with a
Registered Nurse for Mental Defectives
cross – for example
Registered Nurse
(General, Psychiatric and Community)
Registered Midwife/Accoucheur
Registered General Nurse
Enrolled Nurse
Registered Psychiatric Nurse
Enrolled Midwife
Enrolled Nursing Auxiliary
(previously called Enrolled Nursing Assistant)
Registered Mental Nurse
DECLARATION
Answer these four questions with a definite “YES” or “NO” by making a cross in the appropriate block. If the reply to
any of the questions is “YES”, full particulars must be submitted together with the application.
WARNING:
An incorrect answer to any of these questions could lead to professional conduct action being taken against you.
If you are in doubt as to how to answer one or more of these questions, please contact the Council for assistance.
“Professional misconduct” means:
unprofessional conduct, disgraceful conduct or improper conduct or any similar offence.
1. Have you ever been convicted of an offence by a court of law in any country?
YES
NO
2. Is a charge of an offence pending against you in any country?
YES
NO
3. Have you ever been convicted of professional misconduct by a professional conduct hearing of
YES
NO
a Nursing Council or similar controlling body in any country?
4. Is a charge of professional misconduct pending against you in any country?
YES
NO
I certify that the information on this application form is true and correct.
Signature of applicant
Date
/
/
Total amount paid
R
,
Please turn over – form continues overleaf
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