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Application for Re-examination Instructions

Application for Re-examination InstructionsIndividuals submitting a Re-examination Application are not eligible for Graduate Nurse or Graduate Practical Nurse status and are no longer eligible for employment in that capacity. All applicants are required to register with Pearson VUE at (866) 496-2539 or via the internet at When your Application is approved, you will be made eligible for the NCLEX and receive your Authorization to Test letter from Pearson VUE. While you may apply at any time, you may not schedule a test date until 45 days have passed since your last attempt. For Instructions on each section of the Application you can view the Examination Application on the web at: 1120, 10/13, Rule FAC1 Page Nurses Educated outside of the United States or in non-NCSBN jurisdictions:Please be aware that, if one of the following two situations apply to you, you will be required to submit a Course-by-Course Credentials Evaluation Report from a Board approved credentials agency as well as proof of Board approved English Competency upon your next Application for examination with the Florida Board of nursing .

*If you answer “Yes” to question F in this section you must submit a self explanation as to why NAME NURSING EDUCATION HISTORY A. NURSING SCHOOL ATTENDED:

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Transcription of Application for Re-examination Instructions

1 Application for Re-examination InstructionsIndividuals submitting a Re-examination Application are not eligible for Graduate Nurse or Graduate Practical Nurse status and are no longer eligible for employment in that capacity. All applicants are required to register with Pearson VUE at (866) 496-2539 or via the internet at When your Application is approved, you will be made eligible for the NCLEX and receive your Authorization to Test letter from Pearson VUE. While you may apply at any time, you may not schedule a test date until 45 days have passed since your last attempt. For Instructions on each section of the Application you can view the Examination Application on the web at: 1120, 10/13, Rule FAC1 Page Nurses Educated outside of the United States or in non-NCSBN jurisdictions:Please be aware that, if one of the following two situations apply to you, you will be required to submit a Course-by-Course Credentials Evaluation Report from a Board approved credentials agency as well as proof of Board approved English Competency upon your next Application for examination with the Florida Board of nursing .

2 For detailed information on this process see our website: (1)Translations of education credentials do not meet statutory requirements and will not be accepted.(2)If it has been more than two years since you last applied to the Florida Board of nursing to take the NCLEX Examination and your previous Education Credentials Report is no longer available or no longer meets the minimum requirements. Please be advised that this requirement applies to all applicants whether the Application submitted is the original Application , or the Application submitted is for Re-examination . Please ensure that your mailing address is up to date throughout the Application Competency RequirementsRule (1)(d), , requires that English competency be demonstrated. The list of methods approved by this rule can be found on our website at: Approved English Competency ExamsIELTS Cambridge/IELTS InternationalMELAB English Language Institute100 East Corson Street, Suite 200500 East Washington StreetPasadena, CA 91103, USAAnn Arbor, MI 48104-2028, USAP hone: (626) 564-2954 Phone: (734) 764-2416, (toll free) (1-866-696-3522)Fax: (626) 564-2981 Fax: (734) 615-6586 Email: : ServicesTOEIC Testing ProgramEducational Testing ServiceEducational Testing Box 6151 Rosedale RoadPrinceton, NJ 08541-61511, USAP rinceton, NJ 08541 USAP hone: (609) 771-7100 Phone: (609) 771-7170 Fax: (609) 734-1560 Email.

3 DH-MQA 1120, 10/13, Rule FAC2 Page Applicants Educated Outside the United States or Graduates from Territories Whose Regulatory nursing Board is not a Member of the National Council of State Boards of nursing (NCSBN): You are required to have a full education credentials review by a Florida approved credentialing agency. An original copy of the report must be sent electronically to the Board of nursing directly from the agency. Applicants are responsible for paying all fees the agency charges for these reports received from credentialing agencies not listed below will not be Records Evaluation Service, Education Research 601 University Avenue, Suite 127 Foundation, , CA 95825-6738, USAPost Office Box 3665 Phone: (916) 921-0790 or 866-411-3737 Culver City, CA 90231-3665, USA866-411-ERES (Toll Free)Phone: (310) 258-9451 Fax: (916) 921-0793 Fax: (310) 342-7086 Email: : Silny & Associates, on Graduates ofInternational Education ConsultantsForeign nursing Schools7101 SW 102 Avenue3600 Market Street, Suite 400 Miami, FL 33173, USAP hiladelphia, PA 19104-2651, USAP hone: (305) 273-1616 Applicant Inquires: (215) 662-0425 Fax: (305) 273-1338 Customer Service Fax: (215) 622-0425 Email: Phone System (to check status): Web.

4 (215) 599-6200 Florida Board Approved EvaluatorsApplicants with questions regarding Visas or work permits should contact the:Bureau of Immigration and Customs Enforcement4255 I Street 20536, USAP hone: 1-800-375-5283 Web: Visa Screening contact the:Commission on Graduates of Foreign nursing Schools (CGFNS)3600 Market StreetPhiladelphia, PA 19104, USAP hone: (215) 349-8767 Web: Licensure by Re-examination Application Florida Board of NursingPO Box 6330 Tallahassee, FL 32314 Phone: (850) 245-4125 IMPORTANT- The name on this Application must match the name on your NCLEX Application to Pearson VUE exactly. Your name not matching exactly as it appears on your identification will result in you not being allowed to take the exam at your scheduled time and cause a substantial increase in costs for re- Application to this Board and to Pearson : First MiddleDate of Birth: Apt.

5 Zip CountryPhysical Location: Apt. No. (Required if mailing address is a Box-See Checklist)City State Zip Country Home/Cell Telephone (Input with dashes) Work/Cell Telephone (Input with dashes) Place of Birth Mother's Maiden (Surname) NameSEX:RACE: Registered Nurse (RN) 1701- $ Practical Nurse (LPN) 1702- $ $ FeeTotal fee includes the following:An applicant, who is denied licensure, or withdraws the Application prior to licensure, is entitled to a refund of $ signed request to withdraw or for a refund must be made in writing. Fees are refundable for up to 3 years from the date of receipt of initial exam fee. Your previous Application fees cannot be used for a new 1120, 10/13, Rule FAC3 Page Do Not Write in this Space For Revenue Receipting Only Choose your Application type:Please complete this Application in its entirety prior to printing.

6 Last/SurnameStreet/ Box StateMailing Address: (Give the address where mail and your license should be sent) MM/DD/YYYYS treet Male Female White Black Asian/Pacific Islander Hispanic OtherWe are required to ask that you furnish the following information as part of your voluntary compliance with Section 2, Uniform Guidelines on Employee Selection Procedure (1978) 43 FR 38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure. EQUAL OPPORTUNITY DATA:PERSONAL INFORMATIONFax: (850) 617-6460 Website: : must be paid in the form of a cashier's check or money order, made payable to: DOH Florida Board of NursingIf you have never taken the examination for the State of Florida, you will need to submit an examination Application , not the Re-examination Application .

7 You can find it at : this Application to:*If you answer Yes to question F in this section you must submit a self explanation as to whyNAME nursing EDUCATION HISTORYA. nursing school ATTENDED: City:State: Country:B. Program Type: C. Date Graduated (MM/YYYY) BACKGROUNDA ttach additional sheets, if necessaryA. List all name(s) by which you have been known in the What name(s) did you use when you received your nursing education? C. What name did you use when you were first licensed? you ever been denied or is there now any proceeding to deny your Application for any healthcare license to practice in Florida or any other state, jurisdiction or country? G. List all nursing licenses (active, inactive or lapsed) (attach an additional sheet, if necessary) State/Country RN or LPN Date of LicensureStatus of License and Expiry DateLicense No.

8 DH-MQA 1120, 10/13, Rule FAC4 Page Yes No DIPL LPN DateHave you ever applied for licensure by examination in Florida, as a you ever been licensed in Florida as aLPNRN?LPNRN?Dateyou are answering Yes to this Notification: If you want to be notified of the status of your Application by email please check the "Yes" box and write your email address on the line provided below. If you choose this form of notification, you will receive information regarding your Application file through email. You will be responsible for checking your email regularly and updating your email address with the Board office at: want to be notified by email: Email Address: Yes NoUnder Florida law, email addresses are public records. If you do not want your e-mail address released inresponse to a public records request, do not provide an email address or send electronic mail to our contact the office by phone or in PREVENTION OF MEDICAL ERRORS REQUIREMENTC ompletion of a two-hour course on the Prevention of Medical Errors is required prior to licensure.

9 This course must be from an approved Florida Board of nursing provider. Courses can be found online at I have completed a 2 hour course on the Prevention of Medical Errors as required by Florida law. I have NOT completed a 2 hour course on the Prevention of Medical Errors as required by Florida law.*Applicants who check this box must subsequently submit proof of completion.*Applicants who check this box do not need to submit proof of HISTORY Answers to commonly asked questions can be found on our website at: Have you EVER been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld. Reckless driving, driving while license suspended or revoked (DWLSR), driving under the influence (DUI) or driving while impaired (DWI) are not minor traffic offenses for purposes of this you answered Yes you are required to send the following items: Yes NoSelf Explanation describing in detail the circumstances surrounding each offense; including dates, city and state, charges and final Dispositions and Arrest Records for all offenses.

10 The Clerk of the Court in the arresting jurisdiction will provide you with these documents. Unavailability of these documents mustcome in the form of a letter from the Clerk of the of Sentence Documents. You may obtain document from the Departmentof Corrections. The report must include the start date, end date and that the conditions were (3) current (written within the last year) professional Letters of Recommendation. Failure to disclose information in this section may result in a denial of your have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retention, privacy and right to challenge incorrect criminal history records and the Privacy Statement document from the Federal Bureau of Investigation. (Found behind this Application .)The Board will not receive your Livescan results if you do not affirm the above statement by checking this box.


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