SALPN Emergency Registration & Licensure Extension Application Form

First Name: *

Last Name: *

Registration Number: *

Did you obtain employment while registered with emergency licensure to assist with or support in the COVID-19 pandemic? *

Yes

If yes, please indicate where you are employed. *

Facility Name

Location

Area of Nursing

Full-time/ Part-time/ Casual

Start Date

Expected End Date

Do you have a letter of offer or documentation confirming your current employment? *

Yes

If yes, please upload the documentation here.

Maximum upload size: 268.44MB

Were you required to provide your new employer with an updated criminal record check upon hire? *

Yes

Non Applicable

If yes, please upload a copy here

Maximum upload size: 268.44MB