Nurse Form 1 - New York State Education Department

1 Nurse Form 1. Application for Licensure The University of the State of New york The State Education Department Applicants Must Complete All Pages Of This Application In Ink Office of the Professions All applicants for licensure must complete this form and submit it with the appropriate licensure and Division of Professional Licensing Services registration fee ($143) directly to the Office of the Professions at the address at the end of this form. You must answer all questions and provide all information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review. You must sign and date the Affidavit on this form in the presence of a Notary Public. 1. Check what you are applying for Registered Professional Nurse 22 $143 ER Licensed Practical Nurse 10 $143 ER. 2. Social Security Number 3. Birth Date Month Day Year (Leave this blank if you do not have a Social Security Number).

2 The name listed on your application for licensure, the name on your photo identification, and the name listed on your NCLEX. application must ALL match EXACTLY. If your name does not exactly match in all instances it will delay your authorization to test (ATT), you may not be allowed to take the exam at your scheduled time and you may incur additional fees to test. 4. Print Name Last First 6. Telephone/Email Address Middle Daytime Phone Home or Business Licensee business address, phone and email address are public information. Failure to indicate business or home on this form for each item will deem it public information. 5. Mailing Address Home or Business Area Code Phone (You must notify the Department promptly of any address or name changes). Email Address (please print clearly). Line 1 Home or Business Line 2. Line 3. 7. New york State DMV ID Number City (Driver or Non-Driver ID).

3 State ZIP Code (Leave this blank if you do not have a Country/ New york State DMV ID Number). Province 8. Reasonable Testing Accommodations for Individuals with Disabilities. (check if applicable). I have been diagnosed as having a disability and require special testing accommodations and am submitting the Request for Reasonable Testing Accommodations form to the address at the end of the form. I understand that I will not be able to test until I submit the appropriate documentation and am approved to test with accommodations. (Visit the Office of the Professions' Web site at for information on obtaining the form.). 9. Name as it appears on degree or other credentials (if different from above). 10. Have you previously applied for New york State licensure in any profession licensed under New york State Yes No Education Law? If "yes", in what profession(s)? 11.

4 Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime Yes No (felony or misdemeanor) in any court? 12. Are criminal charges pending against you in any court? Yes No 13. Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, Yes No accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you? 14. Are charges pending against you in any jurisdiction for any sort of professional misconduct? Yes No 15. Has any hospital or licensed facility restricted or terminated your professional training, employment, or Yes No privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures?

5 NOTE: If you answer "Yes" to any questions numbered 11-15, submit a letter giving a complete detailed explanation. Include copies of any court records including a Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. If the court can no longer provide documentation, you must request, from the court, a letter stating why they cannot provide the documents. While your application is pending, you must notify the Division of Professional Licensing Services if the answers to any of these questions have changed. Nurse Form 1, Page 1 of 4, Revised 1/18. 16. If you have ever taken the SBTP, NCLEX, or a State -constructed examination for licensure as either a Registered Professional Nurse or a Licensed Practical Nurse in the United states or its territories (except New york State ), complete the following: SBTP, NCLEX or State -Constructed Examination License Number, State or Territory* Profession(s).

6 If Granted Date Examination *If you took the NCLEX or SBTP Examination, send Form 3 to the State in which you passed the licensing examination or request verification from Nursys. 17. You must complete all information for all schools/colleges/universities attended or your application will be considered incomplete. Attach additional sheets if necessary. Note: If you are applying for licensure as a licensed practical Nurse and you did not graduate from a New york State approved nursing program, you must submit a copy of your high school or secondary school diploma or transcript in the original language with your Form 1. If you were educated outside the or a Canadian province other than Quebec with a BN, BSN or BScN after January 1, 2015), submit a copy of your nursing diploma in the original language. Name of Elementary or Primary School City State /Province Country Number of years attended Attendance from to Completion date mo.

7 Yr. mo. yr. mo. yr. Name of High School/Secondary School or GED Diploma Issuer City State /Province Country Number of years attended Attendance from to Completion date mo. yr. mo. yr. mo. yr. Nursing Program Name of School City State /Province Country Major/Concentration Number of years attended Attendance from to mo. yr. mo. yr. Title of Degree/Diploma/Certificate awarded (in original language) Or still in progress Other Postsecondary Education 1. Name of School City State /Province Country Major/Concentration Number of years attended Attendance from to mo. yr. mo. yr. Title of Degree/Diploma/Certificate awarded (in original language). 2. Name of School City State /Province Country Major/Concentration Number of years attended Attendance from to mo. yr. mo. yr. Title of Degree/Diploma/Certificate awarded (in original language). Nurse Form 1, Page 2 of 4, Revised 1/18.

8 18. Do you now hold, or have you ever held, a license or certificate to practice any profession* in any jurisdiction? Yes No If yes, list each license/certificate, State or jurisdiction and provide appropriate information in the columns below. A Form 3 must be submitted for each professional license/certificate listed unless it is a license/certificate issued by the New york State Education Department . See the Applicant instructions on Form 3 for specific information about completing and submitting the form. *Profession is defined as professional titles licensed under New york State Education Law. Date License/Certificate License/Certificate Limitations Professional Title State or Jurisdiction Issued Number on License/Certificate 19. Child Support Obligation Everyone applying for a professional license, permit, or registration, or any renewal thereof, must file a written statement that, as of the date of the filing, she or he is, or is not, under an obligation to pay child support*.

9 Individuals who are four months or more in arrears in child support or who have failed to comply with a summons, subpoena or warrant relating to a paternity or child support proceeding may be subject to suspension of their business, professional, drivers and/or recreational licenses and permits. The intentional submission of false written statements for the purpose of frustrating or defeating the lawful enforcement of support obligations is punishable under section of the Penal Law. You must complete this section before we can issue the credential for which you have applied. Individuals who are not in compliance with their obligation to pay child support can be issued a credential for no more than six months in order to comply with their child support obligations. CHECK ONLY A OR B BELOW. If you check B, you must check one of the five statements listed below it.

10 A I am not under an obligation to pay child support;. Or B I am under an obligation to pay child support and (please check only one of the following). I am current and am not four months or more in arrears in the payment of child support; or, I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties; or, The child support obligation is the subject of a pending court proceeding; or, I am receiving public assistance or supplemental security income; or, None of the above four statements apply. *New york State General Obligations Law, section 3-503. 20. Citizenship/Immigration Status Federal law and the Regulations of the Commissioner of Education (8 NYCRR ) limit the issuance of professional licenses, registrations and limited permits to United states citizens or qualified aliens. To comply with Federal law and Commissioner's regulation, you must complete this section of this form and check the appropriate box below which indicates your citizenship/immigration status.