Final Endorsement App- 10-13

1 Application checklist Please use the following checklist to help ensure your application is complete. Completed Application with Signature An incomplete application will delay Final approval of that application. All documents become a permanent part of your file and cannot be returned. Applications are reviewed in date order received. Every question on the application must be answered. Be sure to answer all questions honestly. The Board of Nursing may deny your application if you provide false information on your application. Proof of Active Certification Your out-of-state certificate must be Clear/Active and in good standing. Completed Confidential and Exempt from Public Records Disclosure Form Form enclosed Livescan All applications received must include electronically submitted fingerprints through a Livescan provider. The Department of Health accepts electronic fingerprinting offered by Livescan providers that are approved by the Florida Department of Law Enforcement.

2 For a list of approved Livescan vendors BOE 'SFRVFOUMZ "TLFE 2 VFTUJPOT BCPVU -JWFsDBO please visit our website at: Our current ORI number is EDOH0380Z.. IUUQ GMPSJEBTOVSTJOH HPW GPSNT FMFDUSPOJD GJOHFSQSJOUJOH GPSN DOB CZ FYBN QEG . Applications and other additional documents must be mailed to: Department of Health Certified Nursing Assistant Registry 4052 Bald Cypress Way Bin# C-02. Tallahassee, FL 32399-3252. DH-MQA 5022 06/18, Rule , FAC. Important Information Application Updates The Board office must be notified in writing of anything which changes or affects a response given in your application. Failure to do so could result in the delay of application processing or denial of your application. 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. Withdrawal of Application If you decide to withdraw your application, you must make the request in writing.

3 The request must be received prior to the Board considering licensure. Criminal History Any applicant who has ever been found guilty of, or pled guilty or no contest to/nolo contendere, any charge other than a minor traffic offense must list each offense on the application. Failure to disclose criminal history may result in denial of your application. Each application is reviewed on its own merits. Staff cannot make predeterminations in advance as laws and rules do change over time. Violent crimes and repeat offenders are required to be presented to the Board of Nursing for review. Applicants with criminal convictions may be required to submit the following documents: Final Dispositions/Sanctions Final disposition records for offenses can be obtained at the clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the Clerk of the Court attesting to their unavailability.

4 Completion of Probation/Parole Probation records for offenses can be obtained at the clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the Clerk of the Court attesting to their unavailability. Self-Explanation Applicants who have listed offenses on the application must submit a letter in your own words describing the circumstances of the offense. Letters of Recommendation Applicants who have listed offenses on the application must submit 3-5 letters of recommendation from people you have worked for or with. Disciplinary History Any applicant who has ever been denied, had disciplinary action, or surrendered a license to practice in any healthcare profession, in any state, jurisdiction, or country must provide a self-explanation of all occurrences of denial, disciplinary action or surrendering of a license. The State Board(s) of Nursing involved must also submit copies of the administrative complaint and Final order directly to the Florida Board.

5 Applicants are responsible to ensure that the proper documentation is sent to the Florida Board. Any action taken against your license by a state licensing board must be reported on this application. Healthcare Fraud 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. For more information, L. please visit our website at: DH-MQA 5022 06/18, Rule , FAC. Florida Board of Nursing PO Box 6330. Tallahassee, FL 32314. Certified Nursing Phone: (850) 245-4125 Assistant Licensure by Fax: (850) 617-6460. Endorsement Application Website: Email: Please complete this application in its entirety prior to printing. 1. PERSONAL INFORMATION. Name: Date of Birth: Last/Surname First Middle MM/DD/YYYY. Mailing Address: (Give the address where mail and your license should be sent).

6 Box Apt. No. City State Zip Country Home/Cell Telephone (Input with dashes). Physical Location: (Required if mailing address is a Box- This address will be posted on the Department of Health's website.). Street No. City State Zip Country Work/Cell Telephone (Input with dashes). EQUAL OPPORTUNITY DATA: We 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 CFR 38295 and 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. SEX: Male Female RACE: White Black or African American Hispanic American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Two or More Races DH-MQA 5022 06/18, Rule , FAC. Page 1. NAME. Email 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.

7 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: I want to be notified by email Yes No Email Address: Under Florida law, email addresses are public records. If you do not want your e-mail address released in response to a public records request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing. 2. APPLICANT BACKGROUND Attach additional sheets, if necessary A. List any other name(s) by which you have been known in the past. B. What name(s) did you use when you received your education? C. What name did you use when you were first licensed? D. Have you ever applied for licensure by examination in Florida, as a CNA? Date Yes No E. Have you ever applied for licensure by Endorsement in Florida, as a CNA?

8 Date Yes No F. Have you ever been licensed in Florida as a CNA? Date Yes No G.* Have you ever been denied or is there now any proceeding to deny your application for any health care license to practice in Florida or any other state, jurisdiction or country? Yes No *If you answer Yes to question G in this section, you must submit a self explanation as to why you are answering Yes to this question. DH-MQA 5022 06/18, Rule , FAC. Page 2. NAME. List all CNA licenses ( active, inactive or lapsed). State/Country License No. License Type Date of Licensure Status of License and Expiry Date The Florida Board of Nursing requires verification of licensure from from a state where you have a current active license. 3. CRIMINAL HISTORY Answers to commonly asked questions can be found on our website at: #faqs A. Yes No 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?

9 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? C. Yes No Have you EVER been adjudicated delinquent? Failure to disclose information in this section may result in a denial of your application. If you answered Yes to any 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.

10 Completion of Sentence Documents. You may obtain documents from the Department of Corrections. The report must include the start date, end date, and state that the conditions have been met. Three (3) current (written within the last year) Letters of Recommendation. DH-MQA 5022 06/18, Rule , FAC. Page 3. NAME. 4. Electronic Fingerprinting: (Required for ALL applicants). All applicants, including out-of-state and out-of-country applicants, are required to submit their fingerprints electronically. The Department of Health accepts electronic fingerprinting offered by Livescan device providers that are approved by the Florida Department of Law Enforcement. For a list of approved Livescan vendors, please visit our website at : Typically background results submitted by Livescan are received by the Board within 24-72 hours of being processed. The Board of Nursing's ORI number is: EDOH0380Z. The Board cannot accept hard fingerprint cards or results.