Nursing Registration Form
The following information identifies the applicant to the Nursing Regulatory Body. Once populated, this form will be
generated for each jurisdiction where the applicant is or was registered. Ensure that the information is correct, then sign and
date each form. Provide each populated form to the respective Regulatory Body to be completed and mailed directly to
NNAS.
PART A: PERSONAL INFORMATION
NNAS ID Number: 9491862 Application Number: 418057
First/Given Name: VANESSA JOY Date of Birth: November 5, 1985
Middle Name: MARCOS Phone Number: +15068899783
Last/Family Name: CANTONJOS Email Address: vahvan10@[Link]
Other Names: VANESSA JOY MARCOS
Name used when registration/license was issued: VANESSA JOY MARCOS CANTONJOS
Mailing Address of Applicant:
Address 1: 55 Forest Street
Address 2: Apt.4
City/Town: Cap pele
Province/State/Territory: New Brunswick
Postal Code/Zip Code: E4N 1T2
Country: Canada
Name of nursing Jurisdiction/Registering Board/Authority: Professional Regulation Commission
Mailing address of Jurisdiction/Registering Board/Authority:
Address 1: P.O. Box 2038
Address 2:
City/Town: Manila
Province/State/Territory:
Postal Code/Zip Code: 1008
Country: Philippines
I, VANESSA JOY MARCOS CANTONJOS hereby give my consent to Professional Regulation Commission to provide
the information requested in PART B of this form related to my nurse registration, 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: Date Signed: 16/12/2024
(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.
PART B: NURSING EXAMINATION AND REGISTRATION INFORMATION
THIS FORM IS VALID FOR THE BELOW PERSON AND REGULATORY AUTHORITY
VANESSA JOY MARCOS CANTONJOS ■ Professional Regulation Commission
Order #: 418057 ■ December 14, 2024 ■ Rev: Aug 2017 ■ Page 1 of 4
To be completed by the official licensing authority. Please provide the following information (in English) concerning the
nursing examination and nursing program of this applicant. Spell out all names fully (no initials or abbreviations). Please
mail the completed form directly to NNAS.
Do not leave any field blank; mark questions that are not applicable as N/A.
Name of Registrant:
In your jurisdiction, is an examination required for initial nursing registration? ☐ Yes ☐ No
If yes, what is the name of the nursing registration/licensing examination?
In your jurisdiction, what is the method by which this applicant was authorized to practice as a nurse?
☐ Examination ☐ Endorsement
☐ Other (Explain): ___________________________________________________________________________________
___________________________________________________________________________________________________
If by endorsement, from what jurisdiction:
If by examination, what is the language of the nursing examination?
What were this applicant's examination results? ☐ Pass ☐ Fail
Number of examination attempts:
Date when applicant successfully completed the examination:
(dd/mm/yyyy)
Was the nursing program recognized or approved in the jurisdiction in which it was completed as qualifying the
applicant to practice in that jurisdiction as the same level of nurse?
☐ Yes ☐ No (Explain): __________________________________________________________________________
________________________________________________________________________________________
The nursing program completed by this applicant was officially recognized, approved, or accredited by:
Date program was initially approved or accredited:
(dd/mm/yyyy)
Date of most recent approval or accreditation:
(dd/mm/yyyy)
THIS FORM IS VALID FOR THE BELOW PERSON AND REGULATORY AUTHORITY
VANESSA JOY MARCOS CANTONJOS ■ Professional Regulation Commission
Order #: 418057 ■ December 14, 2024 ■ Rev: Aug 2017 ■ Page 2 of 4
Please provide the following information concerning the Nursing Registration of this applicant. Spell out all names
fully (no initials or abbreviations), and please do not leave any field blank; mark questions that are not applicable as
N/A.
Title of registration/license:
Current nursing registration/license number:
Previous nursing registration/license number(s) - if applicable:
Status of this applicant's registration/license:
☐ Practicing (active) ☐ Non-Practicing (inactive) ☐ Provisional
☐ Other (explain): ___________________________________________________________________________________
___________________________________________________________________________________________________
Date nursing registration/license was initially issued:
(dd/mm/yyyy)
Date most recent nursing registration/license was issued or renewed (if different):
(dd/mm/yyyy)
Is this a lifetime practice registration/license? ☐ Yes ☐ No
Date registration/license expires or expired (if applicable):
(dd/mm/yyyy)
Is this applicant currently eligible for registration/licensure in your jurisdiction?
☐ Yes ☐ No (Explain): __________________________________________________________________________
_________________________________________________________________________________________
Please provide the following information concerning the registration status/license conditions pertaining to the
nursing registration of this applicant.
If YES is selected for any of the following questions, please attach an explanation for each. YES NO
1. Does registration/license of this registrant have any current conditions or limitations/restrictions? ☐ ☐
2. Is this registrant currently the subject of an inquiry, investigation or a proceeding for conduct
unbecoming, professional misconduct, incompetence or incapacity or any similar investigation or ☐ ☐
proceeding in relation to the practice of nursing or another profession in any jurisdiction?
3. Does this registrant have any physical/mental condition, disorder and/or addiction impairing his/her
ability to practice as a nurse, or another profession? ☐ ☐
4. Has this registrant ever been refused registration/licensure to practice as a nurse? ☐ ☐
5. Has this registrant's registration/license ever been suspended, restricted, surrendered, revoked, or
subject to individual terms and conditions to practice as a nurse, or another profession in any ☐ ☐
jurisdiction?
a. (If yes to above) Did this registrant get his/her license reinstated? ☐ ☐
b. (If yes to above) Date of reinstatement:
(dd/mm/yyyy)
THIS FORM IS VALID FOR THE BELOW PERSON AND REGULATORY AUTHORITY
VANESSA JOY MARCOS CANTONJOS ■ Professional Regulation Commission
Order #: 418057 ■ December 14, 2024 ■ Rev: Aug 2017 ■ Page 3 of 4
PART C: IDENTIFICATION OF OFFICIAL
To be completed by the official authorized to provide registration information for this applicant. Please provide the
following information and spell out all names fully (no initials or abbreviations).
Official authorized to provide registration information
Printed name: Official title:
Phone number: Alternate phone number:
(123-456-7890 format with country code)
Email Address: Website address:
Current physical address of this organization:
Name:
Address 1:
Address 2:
P.O. Box:
City/Town:
Province/State/Territory:
Postal Code/Zip Code:
Country:
By signing below, I certify all information is true and correct to the best of my knowledge and has been provided by
the appropriate official.
Official's Signature: Date Signed:
(dd/mm/yyyy)
[An Official signature, date signed, and seal or stamp are required for this document to be accepted.]
In the space to the left, place the official seal or stamp of this organization.
Please mail this completed form, with any additional documents to:
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 REGULATORY AUTHORITY
VANESSA JOY MARCOS CANTONJOS ■ Professional Regulation Commission
Order #: 418057 ■ December 14, 2024 ■ Rev: Aug 2017 ■ Page 4 of 4