\Written confirmation form for third party authorisation Nursing &
Midwifery
Section A - Applicants details Council
Full name NMC Pin/PRN/Candidate No K
SK
hereby authorise the Nursing & Midwifery Council to discuss with the third party
mentioned below:
* Information concerning my current application to the register
+ Information concerning my current registration
Signature
Date
Section B - Third party details
Is the third party an individual or company?
Company yes if yes please skip to section C on page 2
Individual yes ifyes please fill out the information below
Full name of third party ae
Date of birth eer
Address
Occupation
atin
ship to nurse or midwife
Please now go to Section D on page 2
W: www nme-uk.org 7:0207 333 9333 (+44 207 333 9333 when calling from outside the UK)
Page 1 of 2 Nursing &
Written confirmation form for third party authorisation Mi ‘
idwifery
Council
Applicants details
Mh Full name NMC Pin or PRN Yi
Section C - Company third party details
Company or agency name Baiicin Recro ieme nk
OvASaA BLACSA
Company or agency telephone No
Full address of the company or agency Qog, emacy Corn
the Meads, IQ Kingsmead
Far looro ca Hanthire GUE FST
Please now go to Section D
Section D — Password
The nurse or midwife and the third party must agree on a password which will be
used by the third party in all communications with the Nursing and Midwifery Council
SBAACHIS
Please return this form to: Nursing & Midwifery Council, Registrations, 23 Portland
Place, London, W1B 1PZ.
Alternatively, you can email a scanned copy to
[email protected] or fax
to 020 7681 5300
Please remember your form must be signed and dated in Section A.
W: www.nme-uk.org 7:0207 333 9333 (+44 207 333 9333 when calling from outside the UK)
: Page 2 of 2
