Verification of Registration
College of Nurses of Ontario
101 Davenport Rd., Toronto, ON M5R 3P1
www.cno.org
Telephone: 416 928-0900
Toll-free (Canada): 1 800 387-5526
Fax: 416 928-6507
How to complete this form
Step 1: Applicant should complete section 1.
Step 2: The nursing board should complete section 2.
Step 3: The nursing board should return the fully
completed form to the College of Nurses of
Ontario (CNO) using the mailing address at the
top of this form. See instructions in section 2 of
this form.
Important CNO will not accept this document if sent by the applicant; it must be sent by the nursing board.
Collection of Personal Information Please review the Privacy Policy on CNO’s website (www.cno.org/privacy)
to understand how your personal information will be used.
SECTION 1
To be completed by the applicant
Last name
First name
Applicant’s mailing address
Apt/unit# City
Province/State Postal/Zip Code Country
Date of birth (MM/DD/YYYY)
Gender: ❏ Female ❏ Male
Application number
Previous Name(s)
I _______________________________________________
Please print your name
graduated from _____________________________________________
Name of the School of Nursing
Located in_____________________________________
City
, _________________________________________
Country
on the following date ______________________________
MM/DD/YYYY
I authorize _______________________________________________
Name of Nursing Board of Registration
to provide the information requested in Section 2
and any and all information in its possession to the College of Nurses of Ontario regarding my registration/
licensure. This shall constitute your legal authority to provide any and all information which the College of Nurses
of Ontario shall request which may, in any way, be relevant to my application.
Applicant’s signature:____________________________________ Date: ______________________________
MM/DD/YYYY)
Section 2—Nursing Board of Registration: Please complete Section 2 of this form and send it directly to the College
of Nurses of Ontario in an envelope bearing the letterhead, seal or stamp of the Nursing Board of Registration.
SECTION 2
To be completed by the nursing board Attention applicant: Do not complete Section 2
Name of the school of nursing
Location of the school of nursing
DD / YYYY )
)
Name of the registrant
Date of admission: ( MM /
Date of completion: ( M
M /
DD
/ YYYY
FEB 2021
2021-11
______________________________________________
___________________________________________________
Verification of Registration
❏
❏
SECTION 2 cont’d
1. Type of program completed:
Registered Nurse
Registered Practical Nurse
❏
❏ ❏
❏ ❏
Other (please specify): _______________________
2. Was the nursing program recognized or approved
in the jurisdiction in which the program was
completed as qualifying the applicant to practise
in that jurisdiction as a:
Registered Nurse Yes No
Registered Practical Nurse Yes No
3. The program was officially recognized or approved
by: ____________________________________________
❏
❏
Name of the Nursing Regulatory Body/Board, Licensing/
Recognition/Governmental Authority or Accrediting Organization
4. Registration was obtained by:
Examination
Endorsement
❏ Other (please specify): _______________________
5. If registration was obtained by examination,
please provide the following:
❏ CRNE ❏
❏
❏
CPNRE
NCLEX
Other (please specify): _______________________
❏
__________________________________________________
___________________________________________________
6. Number of times the registration examination was
written: _______________________________________
Date examination passed: ( MM / DD / YYYY )
7. Category of registration:
❏ Registered Nurse
❏ Registered Practical Nurse
❏ Other (please specify): _______________________
8. Original date of registration: ( MM / DD / YYYY )
Expiry date: ( MM / DD / YYYY )
9. Registration/license number issued:______________
10. Registration/license status:
❏ Active/Current
❏ Expired
❏ Other (please specify): _______________________
11. Has the registrant ever been refused registration/
licensure to practise as a nurse in your or any other
jurisdiction?
❏ Yes ❏ No If yes, please attach explanation.
12. Has the registrant’ s registration/license ever been
revoked, suspended, surrendered, restricted or
subject to individual terms and conditions?
❏ Yes ❏ No If yes, please attach explanation.
13. Has the registrant been the subject of a finding of
professional misconduct, incompetence, incapacity,
professional negligence, malpractice or any similar
finding in relation to the practice of nursing or
another profession?
❏ ❏Yes No If yes, please attach explanation.
14. Is the registrant currently the subject of an inquiry,
investigation or a proceeding for professional
misconduct, incompetence or incapacity or any
similar investigation or proceeding in relation to
the practice of nursing?
❏ Yes No If yes, please attach explanation.
If you are a Nursing Regulatory Board in Canada and
the applicant holds a current registration/license in your
jurisdiction, please confirm that the applicant is in Good
Standing by answering the following questions:
15. Is the registrant the subject of any discipline or
fitness to practise order or of any proceeding
or ongoing investigation or of any interim
order or agreement as a result of a complaint,
investigation or proceeding?
❏ Yes ❏ No If yes, please attach explanation.
16. Is the registrant in compliance with the continuing
competency and quality assurance requirements of
your board?
Yes ❏ No If no, please attach explanation.
I
the registrar/secretary acting on behalf of the
Name of the nursing board where applicant/registrant is/was registered
do hereby certify that the foregoing statements are
true statements of the registration record for
Name of the registrant
Name (Please print) Title
Email address
Signature Date (MM/DD/YYYY)
Mail to: College of Nurses of Ontario
101 Davenport Rd., Toronto, ON M5R 3P1
Canada
Place Seal Here
FEB 2021
2021-11
❏
