Advanced Registered Nurse Practitioner Application Packet

1 Advanced Registered Nurse Practitioner Application Packet Contents: 1. List/SSN Information/Mailing 1 page 2. Instructions pages 3. Registered Nurse Practitioner pages 4. Registered Nurse Practitioner pages 5. RCW/WAC and Online Website 1 page Important Social Security Number Information: You are required by state and federal law to provide a social security number with your Application . If you do not have a social security number, please read, complete, and return this form with your Application . A Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance Number (SIN) cannot be substituted.

2 In order to process your request: Mail your Application with initial documentation and your check Send supporting documents not or money order payable to: mailed with initial Application to: Department of Health nursing Commission Box 1099 Box 47864. Olympia, WA 98507-1099 Olympia, WA 98504-7864. Contact us: 360-236-4703. DOH 669-220 September 2018. (This page intentionally left blank.). Application Instructions Checklist FBI background check information: Washington State Law authorizes the Department of Health to obtain fingerprint background checks for licensing purposes.

3 This check is done through the Washington State Patrol and the Federal Bureau of Investigation (FBI). You will be required to submit fingerprints for the background check if you have an out of state address listed on this Application . (Not out of country). You must obtain your fingerprints on the Department of Health fingerprint card. Once we receive your Application we will send you the fingerprint Packet with instructions on how to complete the process. A temporary practice permit will be issued if all other licensing requirements are met pending the completion of this process.

4 All information should be printed clearly in blue or black ink. It is your responsibility to submit the required forms. FF Application Fee. This fee is non-refundable. You can check the online fee page for current fees. FF Select if the following applies: Spouse or Registered Domestic Partner of Military Personnel FF Check appropriate box for method of licensure; Exam or Endorsement FF 1. Demographic Information: Social Security Number: You must list your social security number on your Application . If you do not have a social security number please read, complete, and return this form with your Application .

5 Legal Name: List your full name: first, middle and, last. Definition of legal name: Legal name is the name appearing on your official certificate of birth or, if your name has changed since birth, on an official marriage certificate or an order by a court. The court must have the legal authority to change your name. We may ask you to prove your legal name. If you use any name other than your legal name on this form, your Application may be denied. Birth date: Provide the month, day and year of your birth. Birth place: Provide the city, state and country where you were born.

6 Address: List the address we should use to send any information about your license. Be sure to include the city, state, zip code, county, and country. This will be your permanent address with the Department of Health until we have been notified of a change. See WAC 246-12-310. Phone, Fax and Cell Numbers: List your phone, fax and cell numbers. Email: Provide your email address. Email is our primary form of communication. Your email address is required. Join our Listserv to receive update and news from the nursing Commission. DOH 669-258 September 2018 Page 1 of 3 Other Name(s): Indicate whether you are known or have been known under any other names.

7 If you have a name change, you must notify the Department of Health in writing. You must include proof of this change. See WAC 246-12-300. FF 2. Personal Data Questions: All applicants must answer the same personal data questions. They are focused on your fitness to practice the essential skills of this profession. If you answer yes to any questions in this section, you must provide an appropriate explanation. You must also provide certified documentation referencing the question. If you do not provide this, your Application is incomplete and it will not be considered. Question 5 includes misdemeanors, gross misdemeanors and felonies.

8 You do not have to answer yes if you have been cited for traffic infractions. You may obtain copies of court records through the county courthouse where the conviction, plea, deferred sentence, or suspended sentence was entered. Another jurisdiction refers to any other country, state, federal territory, or military authority. FF 3. Professional Education: List your current or completed nursing program. Indicate degree/certificate/diploma earned. List graduation or anticipated graduation date. Attach additional completed pages if you need more space. FF 4. National Certification: Check the box that applies to your status.

9 A. Currently nationally certified as a Nurse Practitioner or a clinical Nurse specialist. b. Not currently certified but have Registered for a board approved national examination. Provide the following information: Specialty Certifying body FF 5. Endorsement/Employment Verification: Provide employment verification of 250 hours of Advanced nursing practice within the last two years. List all US states that you are currently practicing as an ARNP. FF 6. Requesting Prescriptive Authority: Prescriptive authority attestation must be initialed and dated if you choose to obtain prescriptive authority.

10 See Pain Management. FF 7. Pharmacology Education: This section only needs to be filled out if applying for Prescriptive Authority. FF 8. AIDS Education and Training Attestation: Read the AIDS education and training attestation. AIDS training may include self- study, direct patient care, courses, or formal training. A minimum of seven hours is required. Course content can be found in WAC 246-12-270. If AIDS education was included in your professional education or training, an additional course is not required. DOH 669-258 September 2018 Page 2 of 3. FF 9. Applicant's Attestation: You must sign and date your Application for it to be valid.