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Username

The password must have at least 8 characters, at least 1 digit(s), at least 1 lower case letter(s), at least 1 upper case letter(s), at least 1 non-alphanumeric character(s) such as as *, -, or #

Password

General information

Email address

Email (again)

First name

Surname

City/town

Country

Personal Information

Address (Street Number/Name):

Province:

Postal code:

Phone number (Home) e.g. (204) 942-1320

Phone number (Cell) e.g. (204) 942-1320

Skype name:

Country of origin:

Gender:

Immigration ID (8 numbers, found on official documents issued by Immigration Refugees Cititzenship Canada. 0000-0000 or 00000000.): If you are a Canadian Citizen, write "1"

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I am an Internationally Educated Nurse (You have completed your Nursing Education outside of Canada)

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English Language Proficiency Information

Type of language test?

Listening Score:

Speaking score:

Reading score:

Writing score:

Are you currently attending any English classes?

If yes, Where?

Program Information

Which program stream would you like to participate in?

Do you require information in how to proceed with the nursing licensing bodies/your career plan?

Would you like to participate in IEN navigator services (Assistance with Nursing Licensure in Manitoba.)?

Program referral - How did you hear about our program?

Do you authorize IRCC (Immigration Refugees Citizenship Canada) or an independent research company acting on behalf of CIC to contact you in the future?

Work Information (Please enter N/A if you are unemployed)

Current work status in Canada:

Job title:

Employer:

Employment History Outside of Canada

Job title outside of Canada in the past seven years:

Nursing specialty:

Years of experience in Nursing:

Other than Nursing, I also have a degree in:

An important part of our evaluation plan includes gathering data from The CELBAN Centre/IELTS on clients that have taken part in our program activities and completed official English tests.

Do you agree to allow The CELBAN Centre/IELTS testing centres, to share your results?

There are required fields in this form marked