Client Information Form- Québec

PERSONAL Information
Date of FORMTEXT 09 NOV +966533471681 rosemariejoy_delacruz@yahoo.com.ph
Phone No. Email
Application 2013
Family Name DE LA CRUZ First Name ROSE MARIE JOY Date of Birth (Y-M- 1981-OCT-09
D)
Street Address AL AROUBA ROAD P.O. Place of Birth TACLOBAN LEYTE, Citizenship FILIPINO
BOX 7191 PHILIPPINES
(city, province, country)
City RIYADH Passport Number EB7608373
Country KINGDOM OF SAUDI Sex male female Country of KINGDOM OF SAUDI ARABIA
ARABIA Residence
Postal Code 11462 Marital Status Select You are currently: studying working unemployed
Been married more other      
than once yes no

FAMILY MEMBERS Includes spouse and all dependent children

Last name at birth First name Relationship Date of birth Place of birth Accompanying
(Y-M-D) (city, country) you to Canada?
DE LA CRUZ JULIENNE MARIE ISABEL DAUGHTER 2002-NOV- TACLOBAN CITY, PHILIPPINES y n
02
DE LA CRUZ HELEANA MARIE DAUGHTER 2006-OCT- TACLOBAN CITY, PHILIPPINES y n
11
                              y n

FAMILY TIES IN QUÉBEC (PERMANENT RESIDENTS OR CANADIAN CITIZENS)

Last name at birth First name Relationship Address Tel no.
                             
                             
                             
EDUCATION: excluding elementary/primary school N.B.: Please specify if PRIVATE or STATE EDUCATIONAL INSTITUTION

Private

State
From To YEAR
Language of
Name of Educational Institution/Country Name of Diploma Specialization diploma
YYYY MM YYYY MM instruction
obtained
1994 6 1998 3 LEYTE NATIONAL HIGH SCHOOL/ PHILIPPINES HIGH SCHOOL HIGH SCHOOL 1998 FILIPINO/
DIPLOMA ENGLISH
1998 6 1999 3 LEYTE INSTITUTE OF TECHNOLOGY/ NOT APPLICABLE BACHELOR OF NOT FILIPINO/
PHILIPPPINES SCIENCE IN APPLICAB ENGLISH
CHEMICAL LE
ENGINEERING
1999 6 2004 3 REMEDIOS T.ROMUALDEZ MEDICAL COLLEGE BACHELOR OF 2004 ENGLISH
FOUNDATION/ PHILIPPINES DIPLOMA SCIENCE IN
NURSING
                                             
                                             
                                             
                                             

EMPLOYMENT during the past 5 years, including your own business, military service and internship experience (start with most recent)
From To No. of hours
Name of Enterprise & Country Paid? Job Title & Main Tasks and Duties worked per
YYYY MM DD YYYY MM DD week
2009 3 8 2013 0 0 KING KHALED EYE SPECIALIST HOSPITAL/ y n REGISTERED NURSE 2 44 HRS
KINGDOM OF SAUDI ARABIA > Demonstrates current opthalmic,medical and
Principal Language used: ENGLISH surgical knowledge with ability to recognize and
apply basic pathophysiology in the disease
process.
> Demonstrates competent technical nursing skills;
administering medications safely,assisting
physicians during patient examinations and other
procedures.
> Develops individualized care plans reflecting
collaboration with other members of the health
team.
> Upholds the standards of the International

                     
                     
                     
                     
                     
                     
Do you have a job offer?
Intended place of stay in Québec
Desired job/career in Québec
Council for Nurses-Code of Ethics.
> Performs all duties in a professional, effective
and confidential manner.
> Demonstrates knowledge and skills during
emergency situations and initiate measures
according to resuscitation protocols.
> Delivers admission,pre-operative,post-operative
and discharge teaching according to identified
patient needs.
> Writes timely and accurate reports of relevants
observations to incoming shifts, charge
nurse,nurse manager and physician including
patient and family teaching and evaluation of care.
> Maintains a safe environment for patients,
families and staff by adhering to established safety
and emergency practices and procedures.
> Evaluates effectiveness of patient and family
teaching sessions
      y n            
Principal Language used:            
      y n            
Principal Language used:            
      y n            
Principal Language used:            
      y n            
Principal Language used:            
      y n            
Principal Language used:            
      y n            
Principal Language used:            
yes no If Yes, please specify Employer       Job Position      
MONTREAL If Yes, has your Employer requested for validation with the      
NURSE Ministry of Immigration and Cultural Communities?
RESIDENCES: Please indicate all places where you have resided for the past 10 years
From To
Street address and City Province / Region Country
YYYY MM YYYY MM
2009 3 2013 11 KING KHALED EYE SPECIALIST HOSPITAL HOUSING COMPOUND AL AR RIYAD/ CENTRAL REGION KINGDOM OF SAUDI
AROUBA ROAD. P.O. BOX 7191 RIYADH 11462 ARABIA
1981 10 2013 11 407 ROMUALDEZ ST. SAN MIGUEL, LEYTE LEYTE/ REGION 8 PHILIPPINES
                                 
                                 
                                 
                                 
                                 

STAY IN QUÉBEC

From To

Have you ever: YYYY MM YYYY MM

-Visited Québec?                

-Studied in Québec?                

-Worked in Québec?                

 Have you ever…
Applied for visitor, student of work y Province Select accepted rejected
visa in Canada? n Date (Y-M-D)       waiting for decision
Applied for immigration? y Province Select accepted rejected
n Date (Y-M-D)       waiting for decision
If so, under which program?      
Applied for refugee status? y Province Select accepted rejected
n Date (Y-M-D)       waiting for decision
LANGUAGE SKILLS
FRENCH (Listening) none
FRENCH (Spoken) none
ENGLISH (Listening) Intermediate
ENGLISH (Spoken) Intermediate