CNALS Online Application Form

Date of application
DD slash MM slash YYYY
QNIS Ref No (if known):
Name
Title First Name Last Name
Total number of years of employment as a nurse within the community in Scotland
Any additional years of nursing in the community elsewhere in the UK or overseas
Please note that you must have at least 21 years working in the community to qualify for a Long Service Award
Professional Qualifications
Date Completed Name & Place of Education Institute Qualification
Brief Employment History
Date Position Employer
Address to send Award to:
- Home address
- Work address
Home address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Home Phone No:
Home Mobile No:
Work address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Work Phone No:
Work Mobile No:
Email address:*
Is this a:
- work email
- personal email
Alternate email address:

(if unable to contact you at address above)
The Queen’s Nursing Institute Scotland (QNIS) is committed to protecting your privacy in line with the General Data Protection Regulation (GDPR) 2018.
This policy explains what information we collect, what we will and won’t do with the information, how we protect your data, and your rights under the new law.

To verify that the information supplied on this form is correct we may contact your current employer.

Please provide details below:
Name:
Position:
Working relationship to applicant:
Supporting statement
If you or the person nominating you would like to provide a supporting statement, please complete below:
Comments
This field is for validation purposes and should be left unchanged.

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CNALS Online Application Form

Address to send Award to:

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Date Completed	Name & Place of Education Institute	Qualification

Date	Position	Employer

Address to send Award to:

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