Personal and Employment Details First Name (As per APC)* Middle Name (As per APC) Last Name (As per APC)* Alternate or Preferred Name Date of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Annual Practising Certificate (APC) No.* APC Expiry Date PDRP - Do you have a current PDRP?*Select valueYesNo Email* Home Phone* Mobile Work Phone Postal Address* Street Address Street Address Line 2 City Postal Code Please select residency status:*Please select an option:NZ CitizenNZ Resident VisaNZ Permanent Resident VisaWork VisaAustralian Citizen/Permanent Resident Gender*Select valueMale FemaleGender Diverse Age RangeSelect value<2425-2930-3435-3940-44>45 Ethnicity*Select valueMāoriPacificAsianEuropeanOther Please state your Hapu / Iwi / cultural affiliations (if applicable)Maori and Pacific support Additional support is offered to Maori and Pacific trainees. If you are of Maori or Pacific descent you may be contacted by a cultural support adviser. Clinical Service AreaSelect valueAddiction ServicesAssessment & RehabilitationCancerChild Health, including NeonatologyContinuing Care (elderly)District NursingEmergency & TraumaHigh Dependency UnitIntellectually DisabledIntensive Care/Cardiac CareMedical (including educating patients)Mental Health (community)Mental Health (inpatients)Non-nursing health related management or administrationNot in paid employmentNursing Administration and ManagementNursing EducationObstetrics/MaternityOccupational HealthOther (specify)Other non-nursing paid employmentPaediatric Intensive Care UnitPalliative CarePerioperative Care (Theatre)Primary Health CarePublic HealthSchool HealthSurgicalWorking in another health professionYouth Health Current Nursing Position (Job Title as specified on your contract / Job Description eg CNE CNM Speciality Nurses, Staff Nurse etc) Current Employer* Department* Primary Clinical Area*Select value24 Hour SurgeryAcute CareAdult EmergencyAdult MedicineAged CareAmbulatory CareAnaesthesiaAnaestheticBrain InjuryCardiologyCardiothoracicChild & Family HealthChild and Adolescence Mental HealthClinical LeadershipCommunity HealthCommunity Mental HealthCrisis Mental HealthCritical Care & EmergencyDermatologyDevelopmental DisabilityDiabetesDisability & RehabilitationDrug and Alcohol Mental HealthEmergency/TraumaEndocrinologyForensic PsychiatryGastroenterologyGeneral MedicalGeneral PerioperativeGeneral SurgeryGeneral SurgicalGerontologyGerontology CommunityGerontology MedicineGynaecologyHaematologyHealth Education and PromotionHigh DependencyHome Health CareHyperbaricInfection ControlInfectious DiseasesIntellectual DisabilityIntensive CareInternal MedicineMaori HealthMedical PracticeMental HealthnecNeonatalNeonatal Intensive CareNephrology/RenalNeuroscienceNursing EducationObstetrics and GynaecologyOccupational HealthOncologyOperating RoomOphthalmologyOrthopaedicOutpatients departmentPaediatric Intensive CarePaediatricsPain ManagementPalliative CarePathology Post Part 1Pathology Pre Part 1Perioperative Plastic Surgery & BurnsPre VocationalPrimary Health Care - GeneralPsychiatric RehabilitationPsychogeriatric CarePublic HealthRadiologyRecoveryRegional Training SupportRehabilitationRemote or Rural AreaRespiratorySchool HealthSexual HealthShort Stay SurgicalSpinalUnder 5 years other than Child & Family HealthUnder 5 years other than Practice NurseUrologyVascularWomen's HealthWound CareYouth Health Duration in this position* FTE Primary Position*Select value1.00 0.9 0.80.750.70.60.50.40.30.2 Direct Managers email address* Do you have a second nursing job?YesNoIf you do not have a secondary nursing position move to page 5 to continue your application. ---> Secondary Nursing Position (Job Title as specified on your contract / Job Description eg CNE CNM Speciality Nurses, Staff Nurse etc) Secondary Employer Secondary Department FTE Secondary PositionSelect value1.00 0.90.80.750.70.60.50.40.30.2 Secondary Role TypeSelect valueFull TimePart Time Duration at secondary position Where did you obtain your original nursing qualification? *New Zealand India Philippines Australia UKUSACanada In which year did you obtain your Nursing qualification (YYYY format)* Higest Qualification Achieved / CompletedPostgraduate CertificatePostgraduate DiplomaPostgraduate Masters DegreePostgraduate Masters Degree with Prescribing Qualification Description Date Completed Educational InstitutionSelect valueThe University of AucklandAuckland University of Technology (AUT)Canturbury UniversityEastern Institute of TechnologyMassey UniversityOtago UniversityVictoria UniversityWhitireia Community PolytechnicOtherPlease select below the year and semester you are applying funding for: Funding Year*20242025Short Term Funding Semester*Select Semester12 The Qualification you intend to complete next*Select valuePost Graduate CertificatePost Graduate DiplomaPost Graduate Diploma - RN PrescribingMastersMasters with Prescribing (Nurse Practitioner)Bachelor with Honours Will you complete this next semester?YesNo Estimated Completion DateLong Term The Qualification you are ultimately working towards*Select valuePostgraduate CertificatePostgraduate DiplomaPostgraduate Diploma - RN PrescribingMastersMaster with Prescribing (Nurse Practitioner)Bachelor with HonorsPlanned Academic Study for this semester Educational Provider*Select valueThe University of AucklandAuckland University of Technology (AUT)Canturbury UniversityEastern Institute of TechnologyMassey UniversityOtago UniversityVictoria UniversityWhitireia Community PolytechnicOther Other Education Provider Have you Enrolled*Select valueYesNo Student ID Number (If you already have one for this university)First Paper i. Paper Name enrolling in this semester* i. Paper Code* i. Points Value*Select value15304560 i. Study Days required [If Known]Second PaperIf you are taking two papers this semester, please contact Stacey Wilson directly.Prior Funding In the past year, have you applied for funding via Te Whatu Ora (HWNZ) and not been approved?YesNo Have you received PG Nursing funding for this particular paper in the past?YesNo Please give reasons for needing funding again Have you sought funds from other sources?YesNo List your sources? Were you successful in securing funding?YesNo Distance from place of work to education providerSelect value<100km100-250km>250km Does this study align with your career plan?*YesNoShort Term - Plan and Goals Career Plan Development Goals - Short Term Career Plan Action Plan - Short Term Career Plan Course(s) - Short Term Career Plan Timeframe for Achievement - Short TermLong Term - Plan and Goals Career Plan Development Goals - Long Term Career Plan Action Plan - Long Term Career Plan Course(s) - Long Term Career Plan Timeframe for Achievement - Long Term I confirm that the information in this application is accurate.YesSubmitResetYou might have to scroll to the top of the page to finalise your application.