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) calendar years (current year first). Ensure that the
information is correct, then sign and date each form. All forms (one for each nursing organization/employer in the
jurisdiction where the applicant was employed) must be mailed directly to NNAS by the employer.
PART A: PERSONAL INFORMATION
NNAS ID Number: 9038422 Application Number: 319912
First/Given Name: Kamaljit Date of Birth: 07/10/1996
Middle Name: Phone Number: +1 (437) 326-3277
Last/Family Name: Kaur Email Address: dhaliwalkamal84@[Link]
Other Names:
Mailing Address of Applicant:
Address 1: 59 Mount McKinley Lane
Address 2:
City/Town: Brampton
Province/State/Territory: Ontario
Postal Code/Zip Code: L6R2C2
Country: Canada
Name of the Facility or Organization where employed: Moga Medicity Hospital
Mailing Address of Employer:
Address 1: Dutt Road,Mandir Wali Gali
Address 2:
City/Town: Moga
Province/State/Territory: Punjab
Postal Code/Zip Code: 142001
Country: India
Name of Supervisor: Jagjit Singh
Title/Position of Supervisor: Administrator
I, Kamaljit Kaur hereby give my consent to Moga Medicity Hospital 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 NNAS at the
following address:
NNAS
P.O. Box 8658
Philadelphia, PA 19101-8658
USA
Applicant's Signature: Kamaljit kaur Date Signed: 14/07/2022
(dd/mm/yyyy)
If you have any questions, please contact NNAS via +1 (215) 349-9370 or use the Contact Us option in your applicant portal.
THIS FORM IS VALID FOR THE BELOW PERSON AND EMPLOYER
Kamaljit Kaur ■ Moga Medicity Hospital
Order #: 319912 ■ July 14, 2022 ■ Rev: Aug 2017 ■ Page 1 of 3
PART B: EMPLOYER 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 title, please fill out additional forms for each title held.
Do not leave any field blank; mark questions that are not applicable as N/A.
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
☐ Other (explain): ___________________________________________________________________________________
___________________________________________________________________________________________________
Name of the practice setting area or unit in which this applicant worked:
☐ Medicine ☐ Surgery ☐ Pediatrics/Children ☐ Psychiatry/Mental Health
☐ Geriatrics ☐ Community ☐ Obstetrics ☐ General
☐ Other (explain): __________________________________________________________________________________
__________________________________________________________________________________________________
Describe characteristics of patient population, (patients cared for) in the area(s) or unit(s) where this applicant
worked:
Number of total nursing practice hours worked per year for each of the last five (5) calendar years (not hours per
week), with Year 1 being the most recent calendar year worked (as applicable):
Year 1 (2022): hrs. Year 2 (2021): hrs. Year 3 (2020): hrs.
Year 4 (2019): hrs. Year 5 (2018): hrs.
Date this applicant started employment: _____________________
(dd/mm/yyyy)
Is this applicant still employed? ☐ Yes ☐ No
If No, date this applicant ended his/her last shift of employment:
(dd/mm/yyyy)
Date this applicant ended employment:
(dd/mm/yyyy)
THIS FORM IS VALID FOR THE BELOW PERSON AND EMPLOYER
Kamaljit Kaur ■ Moga Medicity Hospital
Order #: 319912 ■ July 14, 2022 ■ Rev: Aug 2017 ■ Page 2 of 3
Employment category/type:
☐ Licensed Practical Nurse ☐ Enrolled Nurse ☐ Registered Nurse
☐ Registered Psychiatric Nurse ☐ Registered Mental Health Nurse
☐ Other (explain): __________________________________________________________________________________
__________________________________________________________________________________________________
Has this applicant ever been disciplined or allowed to resign? ☐ Yes ☐ No
What was the primary language used in this applicant's practice setting?
What was the primary language of the patient population for which this applicant provided nursing services?
PART C: IDENTIFICATION OF EMPLOYER SUPERVISOR
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).
Printed name: Official title:
Phone number: Alternate phone number:
(123-456-7890 format with country code)
Email Address: Website address:
By signing below, I certify all information is true and correct to the best of my knowledge.
Supervisor's Signature: Date Signed:
(dd/mm/yyyy)
[Official signature and signed date are required for this document to be accepted.]
All information added to this form, or attached to this form is confidential. To ensure acceptance: send this completed
form directly to NNAS in an envelope bearing this organization's logo and return address.
Postal Mailing Address By Courier
NNAS NNAS
P.O. Box 8658 3600 Market Street, Suite 400
Philadelphia, PA 19101-8658 Philadelphia, PA 19104-2651
USA USA
If you have any questions, please contact NNAS via +1 (215) 349-9370.
THIS FORM IS VALID FOR THE BELOW PERSON AND EMPLOYER
Kamaljit Kaur ■ Moga Medicity Hospital
Order #: 319912 ■ July 14, 2022 ■ Rev: Aug 2017 ■ Page 3 of 3
