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Form37 All Employment Verification

This document is a Nursing Employment Verification form used by the BC College of Nurses and Midwives (BCCNM) to assess applicants for registration. It requires the applicant to provide personal and employment information, consent for information release, and for employers to complete sections regarding the applicant's employment history and conduct. Employers must submit the completed form directly to BCCNM to avoid delays in the application process.

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Карина Хоменко
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35 views3 pages

Form37 All Employment Verification

This document is a Nursing Employment Verification form used by the BC College of Nurses and Midwives (BCCNM) to assess applicants for registration. It requires the applicant to provide personal and employment information, consent for information release, and for employers to complete sections regarding the applicant's employment history and conduct. Employers must submit the completed form directly to BCCNM to avoid delays in the application process.

Uploaded by

Карина Хоменко
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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900 – 200 Granville

St. Vancouver, BC
Tel: 604.742.6200
Toll-free: 1.866.880.7101
Form 37
Canada V6C 1S4 Fax: 604.899.0794
Email: [email protected]
www.bccnm.ca

Nursing Employment Verification


Instructions
• BCCNM will use the information provided in this form to assess the applicant’s application for registration with
the BCCNM. The reference form must be submitted to BCCNM directly by the employer.
• To avoid delays in the application process, make sure Sections A to C are complete, then provide to your
current or previous nursing employer to complete Sections D to G. Provide an Employment Verification for
each nursing employer in the last five years.
• The applicant must submit a resume of their nursing employment to BCCNM.
• The applicant must list all facility names within that health authority that this form is for.

PART A — Personal information (to be completed by applicant)


Last name: First name: BCCNM ID:
Middle name(s): Former name(s) if applicable:

Part B — Employment information (to be completed by applicant)


Area of nursing you work/worked in: Clinical practice Administration Education Research

Facility name:
Health authority (if applicable):
Employer address (Apt/Box/#/Street): City/town:
Province/State: Country: Postal code/zip code:

Manager name:
Title:
Telephone: Email:

Part C — Consent & Declaration (to be completed by applicant)


I give consent to any and all current and previous employers to release information regarding my conduct, fitness, and
competence in nursing to BCCNM to be used solely for the purpose of assessing eligibility for registration in British
Columbia.
I declare that the information I have provided on this form is true and accurate. I understand that falsification of this
document, or the submission of any falsified documents to BCCNM, may be cause for BCCNM to withhold registration,
revoke registration or take other appropriate action.

Signature: Date (mm/dd/yy):

Page 1/2 Form 37 (January 2025)


Part D — Employment information (to be completed by employer)
The individual above has applied for registration with the BC College of Nurses and Midwives (BCCNM). In order to
determine if the applicant meets the requirements for registration, we would appreciate your assistance by
completing the questions below. This form should be completed by HR or the supervisor/manager most familiar with
the appli- cant’s nursing practice during the time of employment. To avoid delays, all sections of this form must be
completed.
Both pages of this form must be sent directly to BCCNM by the employer by email at [email protected].

Date employed from (mm/dd/yy): to:


If currently on LTD, maternity or other type of leave, what date did the leave begin? (mm/dd/yy):
Job title: Full-time Part-time Casual
Department(s) employed in:
Language spoken in the workplace:
Language used for documentation:
Is nursing registration required to hold this position? If yes, please indicate what type of nursing registration:
LPN NP RN RPN Other

Important: Please attach a job description for the position described.

Part E — Nursing practice hours in the past five years (to be completed by employer)
Provide the nursing practice hours for each calendar year (January 1 - December 31) of employment for the past five
years. Hours must only include actual practice hours worked (excluding seniority, vacation, LTD/sick leave, paid/unpaid
leave, etc.
Last year worked: Hours: EXAMPLE:
Previous year: Hours Last year worked: Hours: 1,600
Previous year: Hours 2023 Previous year: Hours: 2,150
Previous year: Hours 2022 Hours: 0
Previous year: Hours Previous year: 2021 Hours: 1,850

Part F — Conduct (to be completed by employer)


Has the applicant ever been investigated, disciplined, terminated or allowed to resign in lieu of termination?
Yes No

Is this individual eligible for rehire? Yes No

Part G — Employer information (to be completed by employer)


Last name: First name:
Title:
Telephone: Email:

Signature: Date (mm/dd/yy):

Page 2/2 Form 37 (January 2025)


IMPORTANT: Please email the completed reference (both pages) directly to [email protected].

Page 3/2 Form 37 (January 2025)

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