Online Member Registration

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Personal Details
Education Background
Work Experience
Declarations and Documents

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South Sudan Nurses and Midwives Association (SSNAMA)

Membership Registration Form

Fill the below form with accurate details. Ensure you fill all the mandatory fields marked with an asterisx (*)

I hereby apply for membership of the South Sudan Nurses and Midwives Association. I am a:

* Mandatory field

Registered Nurse

Registered Midwife

Enrolled/Certified Nurse

Community Midwife

Enrolled/Certified Midwife

Nurse/Midwife

Associate Member

Section A: Registration Type

* Type of registration

Ordinal Registration

Associate Registration

Section B: Personal Detail

* Title

Mr.

Mrs.

Miss

Ms.

Dr.

* Full Names

* Date of Birth

* Place of Birth

* Gender

Male

Female

* Marital status

Single

Married

Divorced

Widowed

Religion

Location of Origin

Country of Origin

Region of Origin

* State

County

Payam

Location of Current Residence

Country of Residence

Region of Residence

State

County

Payam

Section C: Contact Details

Provide your current contact Details below and place next to your preferred Contact Phone Number

* Mobile Number

Office/Business Mobile

* Email Address

* What is your residential area
This is your home address, where you stay.

What is your principal place of practice?
The address at which you predominantly practice the profession and it cannot be A P O Box

Alternative address
Other than your place of work or residence kindly provide another address where you can be reached.

Section D: Academic Qualification

What are the details of your (Cert./Dip./First Degree) Qualifications and examinations / Assessments?

Primary Nursing/Midwifery qualification and examination/assessments?(Cert/Dip./First Degree)

Title of Qualification

Name of Institution (University/College/Examination Body)

Country

Commencement Date

Completion Date

Additional Nursing/Midwifery Post-Basic/Post-Grad qualification and examination/assessments

Name of Institution (University/College/Examination Body)

Country

Commencement Date

Completion Date

Section E: Registration History

What is your health practitioner registration history with other professional body/board/association?

If you have been registered outside of South Sudan, the Board requires a Certificate Of Registration Status or Certificate/Letter of Good Standing from each licensing authority outside of South Sudan in which you are currently, or have previously been registered as a health practitioner during the past three years.

Most recent registration

Name of Board/Council

Country

Profession

Registration From

Registration To

Name of Board/Council

Country

Profession

Registration From

Registration To

Have you previously practiced as a registered nurse, enrolled nurse or Midwives?

No (Go to Section G: Suitability Statement)

Yes (Provide Details below)

What is your Full Practice History? You must attach to your application a signed and dated Curriculum Vitae that describes your full practice history and clinical or skill in training undertaken

Work Experience/ Employment History

Duration

From

Employer/Hospital

Position/Duties

Text Area

Department

Text Area

Duration

From

Employer/Hospital

Text Area

Position/Duties

Text Area

Department

Text Area

Duration

From

Employer/Hospital

Text Area

Position/Duties

Text Area

Department

Text Area

Section G: Declaration

Any other comments
Enter any other important information in this section

* Declaration

I hereby declare that to the best of my knowledge and belief the information provided above are true.

Secction H: Supporting documents attached

South Sudan National ID Card if National