Internationally Educated Nurses Bursary Program Reimbursement

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Personal information on this form is collected by the Department of Health and Wellness under the authority of Section 31(c) of the Freedom of Information and Protection of Privacy Act. It will be used for the purposes of administering your participation in and determining reimbursement of expenses pursuant to the International Educated Nurses Bursary Program. Any information collected may also be shared with your Employer for verification. For more information on the collection, use or disclosure of this information, contact healthworkforce@gov.pe.ca.

Identification

First Name

Middle Initial

Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

For example C1B 0X1 or 12345

Country

Telephone Number

For example 902-555-5555

Email Address

Date of Birth

Are you a Registered Nurse (RN) or Licensed Practical Nurse (LPN)?

Prince Edward Island College of Nursing & Midwifery (PEICNM) Registration Number