Bilingual / French Nursing Grant Application <insert text> Step 1 of 5 0% Section AName First Name Middle Name (if applicable) Surname Email Mailing Address Apt. Suite # (if applicable) – Street # P.O. Box (if applicable) City / Town Postal Code Home PhoneWork PhoneCellIs the address above the same as the mailing address? Yes No Permanent Address Apt. Suite # (if applicable) – Street # P.O. Box (if applicable) City / Town Postal Code Section BPLEASE REMEMBER TO ATTACH A PHOTOCOPY OF YOUR MANITOBA REGISTRATION / LICENSE and LETTER OF EMPLOYMENT for each grant (if applying for other grants).Nursing Category Licensed Practical Nurse (LPN) Registered Nurse (RN) Registered Nurses - Extended Practice or Nurse Practitioner (RNEP/ NP) Registered Psychiatric Nurse (RPN) Grad Nurse? Yes No Registration / License # For Grad Nurses, expected date of registration / licensure? YYYY dash MM dash DD Attach a photocopy of your registration / license.Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.Attach a copy of your letter of employment.Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.Have you applied previously for other grants with NRRF? Yes No Which Grant? Date received / applied for? MM slash DD slash YYYY Section CHow did you hear about the Nurses Recruitment and Retention Fund?(Please check and fill where applicable) Advertising or Publication Employer Internet Job Fair other What educational institute did you attend? Your date of graduation? DD dash MM dash YYYY The date of your initial registration with CRNM / CLPNM / CRPNM? DD dash MM dash YYYY Were you previously employed in nursing, in a position that required Bilingualism / French language requirement? Yes No Employer's Name / Facility / Region? Area of Nursing? Start Date? MM slash DD slash YYYY End Date? MM slash DD slash YYYY # of months worked? Section D - Employment in ManitobaName of Employer or Organization Department Email Employer's Address Street Address P.O. Box (if applicable) City / Town Postal Code Your position (ex. RN II) Phone Section E - Employee Declaration & AgreementI Declare that:I am not currently in default with any other NRRF program or incentive. I am newly hired into a position where bilingualism/French language is a requirement and was not employed in any such position in the last 6months prior to my application. I have given complete and true information on this form and I understand that failure to do so may prevent my qualifying for assistance in the future. I understand that should I change positions or employers while fulfilling my service agreement, I must complete a revised service agreement and complete the time remaining in my service agreement with NRRF. I have read and understand the Bilingual / French Nursing Grant Policy.Employment since?I have been employed continuously in the nursing profession in Manitoba and I intend to continue my employment in an approved bilingual / French requirement nursing position as a nurse in Manitoba for not less than 12 months from that date at 0.6 EFT or higher. YYYY dash MM dash DD I agree that:If I am not employed in an approved bilingual / French requirement nursing position in Manitoba, as a nurse for the full 12 months at 0.6 EFT or higher: 1. I will notify the Nurses Recruitment and Retention Fund in writing of the last day of employment immediately upon tendering my resignation or termination. 2. I will repay all of my financial assistance (pro-rated) to the Nurses Recruitment and Retention Fund. I agree.I UNDERSTAND THAT MY EMPLOYMENT MUST BE FOR A CONTINUOUS TERM OF 12 MONTHS. MANITOBA MAY EXTEND THE TIME TO COMPLETE THE TERM OF 12 MONTHS OR GRANT TEMPORARY ABSENCES FOR PREGNANCY OR HEALTH RELATED MATTERS. EACH REQUEST WILL BE EXAMINED ON ITS OWN MERITS BY THE NURSES RECRUITMENT AND RETENTION FUND FOR A FINAL DECISION. SHOULD MY CONTACT AND JOB INFORMATION CHANGE, I WILL NOTIFY THE FUND IMMEDIATELY.Signature Reset signature Signature locked. Reset to sign again Date YYYY dash MM dash DD Section F - Employer Certification & Agreement
