8/16/2019 Third Party Application Form2

1/2

Written confirmation form for third party authorisation

Section A – Applicants details

Section B – Third party details

W: www.nmc-uk.org T:0207 333 9333 (!! 207 333 9333 when ca""ing from outside the #$ %&age ' of 2

Full name  NMC Pin/PRN/Candidate No  

) here*y authorise the +ursing , idwifery ounci" to discuss with the third partymentioned *e"ow:

• )nformation concerning my current app"ication to the register

• )nformation concerning my current registration

/ignature

ate

)s the third party an indi1idua" or company

ompany yes if yes please skip to section C on page 2  

)ndi1idua" yes if yes please fill out the information belo

u"" name of third party

ate of *irth

 4ddress

5ccupation

6e"ationship to nurse or midwife

Please now go to Section D on page 2 

!!/MM/""""

!!/MM/""""

8/16/2019 Third Party Application Form2

2/2

Written confirmation form for third party authorisation

Applicants details

Section C – Company third party details

Section ! – Passord

&"ease return this form to: Nursin# $ Midifery Council% Re#istrations% &' PortlandPlace% (ondon% )*B *P+,

 4"ternati1e"y you can emai" a scanned copy to thirdpartyen8uiriesnmc-uk.org or fa to020 7;