The College of Nursing ABN 43 000 106 829 RN/EN Distance Education Enrolment Form
For Continuing Distance Education Courses Only   Please Complete All Parts of this Form   Course Details
	Select Course:    Immunisation for registered nurses -- 062
	Preferred Enrolment Month:	JanFebMarAprMayJunJulAugSepOctNovDec
Personal Details
	Title:	MrMsMrsProfDr
	First Name:	*
	Surname:	*
	Other Names (Alias):
	Staff Number:	*
	Date of Birth:
	Address:	*
	Suburb:	*
	State:	NSW VIC ACT QLD WA TAS NT
	Postcode:	*
	Mobile no:
	Phone no:	*
	E-mail address:	*
	Are you of Aboriginal or Torres Strait Island descent?   If yes, please specify	Yes No
Employment Details
	Staff Position:
	Ward/Unit:
	Place of Employment:
	Area Health Service:
	Work Telephone:
	Is your place of employment:	Private Public Other
University Credit
	Are you enrolling in this course as an elective for university credit?	Yes No
	University:
	Degree:
	Faculty:
	Contact Lecturer:
	Address:
	Final date for submission of results:
Upload Important Documents
	Please include a copy of your current Authority to Practise as a nurse (RN or EN) with your completed enrolment form   Please use winzip if you want to upload multiple files.
	Upload Important Documents:
Geographical Roll
	Do you wish to have your name included on the geographical roll?	Yes No
The College of Nursing Membership
	Are you a member of this College?	Yes No
	If yes, please specify Membership No:
	Course Fees (A$):
	Method of Payment?	By Student By Employer