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 Livescanprovider.

2 The Department of health accepts electronic fingerprinting offered by Livescanproviders that are approved by the Florida Department of Law Enforcement. For a list of approved Livescan vendors BOE 'SFRVFOUMZ "TLFE 2 VFTUJPOT BCPVU -JWFsDBO please visit our website at: current ORI number is EDOH4400Z. 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 32399-3252DH-MQA 5022 06/18, Rule , FACI mportant Information Application UpdatesThe Board office must be notified in writing of anything which changes or affects a response given in your application.

3 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, licensurestatus or disciplinary action in another state, or an incorrect answer to a of ApplicationIf you decide to withdraw your application, you must make the request in writing. The request must be received prior to the Board considering HistoryAny 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.

4 Staff cannot make predeterminations in advance as laws and rules do change over crimes and repeat offenders are required to be presented to the Board of Nursing for with criminal convictions may be required to submit the following documents: Final Dispositions/Sanctions Final disposition records for offenses can be obtained at theclerk 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 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 Applicants who have listed offenses on the application must submit a letter in your own words describing the circumstances of the of Recommendation Applicants who have listed offenses on the application must submit3-5 letters of recommendation from people you have worked for or HistoryAny applicant who has ever been denied, had disciplinary action, or surrendered a license to practicein 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.

5 The State Board(s) of Nursing involved must also submit copies of the administrative complaint and Final order directly to the Florida Board. 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 onthis FraudIMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates forexamination 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, Lplease visit our website at: 5022 06/18, Rule , FAC Male Female RACE: Page 11. 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).

6 This information is gathered for statistical andreporting purposes only and does not in any way affect your candidacy for licensure. SEX: PERSONAL INFORMATIONName:Last/Surname First MiddleDate of Birth: MM/DD/YYYYM ailing Address: (Give the address where mail and your license should be sent) Box Apt. State ZipCountryHome/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 State ZipCountryWork/Cell Telephone (Input with dashes) Certified Nursing Assistant Licensure byEndorsement ApplicationWebsite: : complete this application in its entirety prior to Board of Nursing PO Box 6330 Tallahassee, FL 32314 Phone: (850) 245-4125 Fax: (850) 617-6460 WhiteBlack or African AmericanHispanicAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderTwo or More RacesDH-MQA 5022 06/18, Rule , FACPage 2 NAME 2.

7 APPLICANT BACKGROUND Attach additional sheets, if necessaryA. List any other name(s) by which you have been known in the What name(s) did you use when you received your education? C. What name did you use when you were first licensed? D. DateHave you ever applied for licensure by examination in Florida, as a CNA? E. DateHave you ever applied for licensure by Endorsement in Florida, as a CNA? 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. 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 Yes NoEmail Address:Under Florida law, email addresses are public records.

8 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 * Have you ever been denied or is there now any proceeding to deny your application for anyhealth 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 you ever been licensed in Florida as a CNA?DateYes NoYes NoYes NoDH-MQA , FAC5022 06/18, Rule 3 NAMECRIMINAL 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?

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 No Self Explanation describing in detail the circumstances surrounding each offense; including dates,city and state, charges and 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 of Sentence Documents. You may obtain documents from the Departmentof Corrections.

10 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. List all CNA licenses ( active, inactive or lapsed)State/Country License No. License Type Date of Licensure Status of License and Expiry DateThe Florida Board of Nursing requires verification of licensure from from a state where you have a current active license. Failure to disclose information in this section may result in a denial of your you answered Yes to any of the questions above you are required to send the following items:Yes No Have you EVER had any records sealed pursuant to section , , or other statesapplicable statute?