Compact State Information - Florida Board of Nursing

1 Important Information for all Applicants You must have a current Florida LPN or RN license to apply for a multi- State license upgrade. If your declared primary State of residency is another Compact State , you are not eligible for a multi- State license. All sections must be completed in full. Failure to submit a complete application will result in a processing delay. If you provide false Information , the Board of Nursing may deny your application. The Board office must be notified in writing of anything that changes or affects a response given in your application. Failure to do so could result in the delay of application processing, denial of your application or revocation of licensure. Examples: change of name, address, telephone number, arrests or convictions, licensure status or disciplinary action in another State , or an incorrect answer to a question. Compact State Information Florida is a member of the enhanced Nurse Licensure Compact (eNLC).

2 The eNLC allows a registered nurse or licensed practical nurse licensed in a Compact State to practice across State lines in another Compact State without having to obtain a license in the other State unless the nurse moves and declares the new Compact State as his/her new primary State of residence. It is important to remember that the eNLC requires nurses to adhere to the Nursing practice laws and rules of the State in which he/she practices under his/her Compact license. Please note that this does not include Advanced Registered Nurse Practitioners. If a nurse moves from one State to another and establishes residency, the nurse must apply for licensure in that State . Please visit the National Council of State Boards of Nursing (NCSBN) Web site ( ) for a list of states that have implemented the Compact . Primary State of residence as defined by the Compact means the person's declared fixed permanent and principal home for legal purposes; domicile.

3 Proof of primary residence may include but is not limited to: 1) Driver's license with a home address 2) Voter registration card displaying a home address 3) Federal income tax return declaring the primary State of residence; or 4) W2 from US Government or any bureau, division or agency thereof indicating the declared State of residence. If your declared primary State of residence is another Compact State , you are not eligible for a multi- State license; however, you may apply for a single- State license. Requirements for a Multi- State License In addition to Florida being your primary State of residence, the following requirements must be met to qualify for a multi- State license: 1) You must meet Florida 's requirements for initial licensure 2) You must have passed the NCLEX or the SBTPE. 3) Your license status must be clear and unencumbered ( Encumbrance means a revocation or suspension of, or any limitation on, the full and unrestricted practice of Nursing imposed by a licensing Board 4) You must not have a felony conviction 5) You must not be enrolled with IPN or any other treatment program for impaired practitioners 6) You must have a social security number DH-MQA 5024, 01/18, Rule , FAC.

4 Page 1. Do Not Write in this Space For Revenue Receipting Only Florida Board of Nursing Multi- State License PO Box 6330 Upgrade Application Tallahassee, FL 32314. Phone: (850) 245-4125 Website: Fax: (850) 617-64600 Email: Please complete this application in its entirety prior to printing. A fee of $ must be paid in the form of a cashier's check or money order, made payable to: DOH Florida Board of Nursing SELECT LICENSE TO UPGRADE: (You must have a current Florida LPN or RN license that is not expiring within 120 days of applying for this upgrade. If your license needs to be renewed prior to applying for the upgrade, please visit ). Registered Nurse (RN) 1701- $ Licensed Practical Nurse (LPN) 1702- $ Florida License Number: 1. PERSONAL Information . Name: Last/Surname First Middle Mailing Address: (Give the address where mail and your license should be sent). Street Box Apt. No. City State Zip Country Home/Cell Telephone (Input number without dashes).

5 Physical Location: (Required if mailing address is a Box- This address will be posted on the Department's website.). Street Apt. No. City State Zip Country Work/Cell Telephone (Input number without dashes). 2. CRIMINAL HISTORY (Answers to commonly asked questions can be found on our website at: #faqs). Have you EVER been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in A. Yes No 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 question. B. Yes No Have you EVER had any records sealed pursuant to section , , or other states applicable statute? DH-MQA 5024, 01/18, Rule , FAC. 2. NAME. Failure to disclose Information in this section may result in a denial of your application.

6 If you answered Yes to either of the questions above you are required to send the following items: Self Explanation describing in detail the circumstances surrounding each offense; including dates, city and State , charges and final results. Final Dispositions and Arrest Records for all offenses. The Clerk of the Court in the arresting jurisdiction will provide you with these documents. Unavailability of these documents must come in the form of a letter from the Clerk of the Court. Completion of Sentence Documents. You may obtain document from the Department of Corrections. The report must include the start date, end date and that the conditions were met. Three (3) current (written within the last year) professional Letters of Recommendation. 3. CRIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS. IMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates for examination may be excluded from licensure, certification or registration if their felony conviction falls into certain timeframes as established in Section (2), Florida Statutes.

7 If you answer Yes to any of the following questions, please provide a written explanation for each question including the county and State of each termination or conviction, date of each termination or conviction, and copies of supporting documentation to the address below. Supporting documentation includes court dispositions or agency orders where applicable. Have you been convicted of, or entered a plea of guilty or nolo contendere, 1. Yes No regardless of adjudication, to a felony under Chapter 409, (relating to social and economic assistance), Chapter 817, (relating to fraudulent practices), Chapter 893, (relating to drug abuse prevention and control) or a similar felony offense(s) in another State or jurisdiction? If you responded No to the question above, skip to question 2. a. Yes No If Yes to 1, for the felonies of the first or second degree, has it been more than 15 years from the date of the plea, sentence and completion of any subsequent probation?

8 If Yes to 1, for the felonies of the third degree, has it been more than 10 years from the date of the plea, b. Yes No sentence and completion of any subsequent probation? (This question does not apply to felonies of the third degree under Section (6)(a), Florida Statutes). If Yes to 1, for the felonies of the third degree under Section (6)(a), Florida Statutes, has it c. Yes No been more than 5 years from the date of the plea, sentence and completion of any subsequent probation? If Yes to 1, have you successfully completed a drug court program that resulted in the plea for the felony d. Yes No offense being withdrawn or the charges dismissed? (If Yes , please provide supporting documentation). Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, to a felony under 21 ss. 801-970 (relating to controlled substances) or 42. 2. Yes No ss. 1395-1396 (relating to public health, welfare, Medicare and Medicaidissues)?

9 DH-MQA 5024, 01/18, Rule , FAC. 3. NAME. If you responded No to the question above, skip to question 3. a. Yes No If Yes to 2, has it been more than 15 years before the date of application since the sentence and any subsequent period of probation for such conviction or plea ended? 3. Yes No Have you ever been terminated for cause from the Florida Medicaid Program pursuant to Section , Florida Statutes? If you responded No to the question above, skip to question 4. a. Yes No If you have been terminated but reinstated, have you been in good standing with the Florida Medicaid Program for the most recent five years? 4. Yes No Have you ever been terminated for cause, pursuant to the appeals procedures established by the State , from any other State Medicaid program? If you responded No to the question above, skip to question 5. a. Yes No Have you been in good standing with a State Medicaid program for the most recent five years? b.

10 Yes No Did the termination occur at least 20 years before the date of this application? 5. Yes No Are you currently listed on the United States Department of Health and Human Services' Office of Inspector General's List of Excluded Individuals and Entities? LIVESCAN PRIVACY STATEMENT. I 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 in Forms Section of this application). The Board will not receive your Livescan results if you do not affirm the above statement by checking this box. DH-MQA 5024, 01/18, Rule , FAC. 4. NAME. Electronic Fingerprinting: (Required for ALL applicants). All applicants, including out-of- State and out-of-country applicants, are required to submit their fingerprints electronically.