Texas Board of Nursing

1 For Office Use Only: Texas Board of Nursing 333 Guadalupe, Ste. 3-460, Austin, TX 78701-3944 Amount RN Phone: 512-305-7400 -- Web Site: Date Rec'd Delinquent (Expired) License Renewal Form This form is to be used once the license has expired. Processing time is within ten (10) business days once all requirements are Please refer to the enclosed General Instructions, checklist and met. statistical code sheet to assist in completing this form. The Rules pertaining to the maintenance of your license and your eligibility Answer all questions, sign, date, and return both pages.

2 To renew are located at 22 Texas Administrative Code (TAC) chapter 216. and , , , , and Continuing Competency Certificates must accompany late renewals (if applicable). Make your check or money order payable to the Texas Board of Nursing . Fees are non-refundable. The application and payment are valid for one year from the date of receipt in the Board 's office and all licensure requirements must be met within that timeframe. [ ] LATE RN RENEWAL (1 to 90 days past expiration date) Fee: $ [ ] LATE RN RENEWAL (OVER 90 days past expiration date) Fee: $ Name (Last): (First): (M): Legal documentation is required for a name change (see 22 TAC ).

3 RN License Number: Social Security Number: - - Date of Birth: / /. Mo Day Yr (Address) (City) (State/Country) (Zip/Postal Code). ** ** ( ). (E-Mail Address) Business Fax Number *For statistical information below, please use the statistical code sheet provided *Employment Status: *Primary Practice Setting: *Primary Practice Position: *Primary Specialty: *Highest Degree: *Primary Employment Zip: In accordance with the Texas Occupations Code, section , art. 4 and 22 TAC , check one of the following: I declare Texas as my primary state of residence and I have provided a Texas address.

4 I am eligible for a Compact Texas License (I understand that once my Texas license is renewed, my other compact state license(s) will be inactivated, if applicable). I declare Texas as my primary state of residence but I have not provided a Texas address. I am eligible for a Single State Texas License only. (NOTE: If the address you provide is in a Compact State, the BON may seek clarification prior to renewing the license). I am declaring a Non-Compact State as my primary state of residency. My permanent residence is not Texas , however, it is a state not participating in the Nurse Licensure Compact.

5 (*) I am eligible for a Single State Texas License only. I declare that the State of _____ is my primary state of residence and that such constitutes my permanent and principal home for legal purposes. I am employed exclusively in the US military (Active Duty) or with the Federal Government and am requesting a Texas single-state license regardless of my primary state of residence. I declare that the State of _____ is my primary state of residence and that such constitutes my permanent and principal home for legal purposes. (*) Refer to for a list of participating compact states and more detailed information about the Nurse Licensure Compact.

6 NOTE: If you are declaring a Compact State, other than Texas , then you are not eligible to renew your Texas Nursing license. You should contact the Nursing Board of the state which you are declaring and seek guidance in either renewing that Nursing license or obtaining an initial license. Upon re-licensure in Texas , in which states do you intend to practice Nursing electronically _____ _____, telephonically _____, or physically _____ _____. List all states that apply. [ ] No [ ] Yes Have you practiced Nursing by using your Nursing knowledge, skills and abilities within the past four (4) years?

7 Indicate the month and year that you last practiced as a Registered Nurse: Month _____Year If you have practiced as a Registered Nurse sometime within the past four years, please give the name and location of your most recent employer: Employer Name: Address: _. City, State: _. ** The email address that you provide to the Board is required in order to schedule fingerprinting for your criminal background check. The email address that you provide to the Board is subject to release to the public pursuant to the Texas Public Information act. ** Please note that your business fax number is being collected for use by an emergency relief program, as authorized by the Texas Occupations Code and is confidential and not subject to disclosure.

8 Licensee's Name: License Number: Page 2 of 2. Eligibility Questions - Answering the questions below and signing the form is mandatory. 1) [ ] No [ ] Yes *Have you, within the past 24 months or since your last renewal, for any criminal offense, including those pending appeal: A. been arrested and have any pending criminal charges? B. been convicted of a misdemeanor? C. been convicted of a felony? D. pled nolo contendere, no contest, or guilty? E. received deferred adjudication? F. been placed on community supervision or court-ordered probation, whether or not adjudicated guilty?

9 G. been sentenced to serve jail, prison time or court-ordered confinement? H. been granted pre-trial diversion? I. been cited or charged with any violation of the law? J. been subject of a court-martial; Article 15 violation; or received any form of military judgment/. punishment/action? (You may only exclude Class C misdemeanor traffic violations or offenses previously disclosed to the Texas Board of Nursing on an initial licensure or renewal application.). NOTE: Expunged and Sealed Offenses: While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket or citation has, in fact, been expunged or sealed.

10 It is recommended that you submit a copy of the Court Order expunging or sealing the record in question to our office with your application. Failure to reveal an offense, arrest, ticket, or citation that is not in fact expunged or sealed, may subject your license to a disciplinary order and fine. Non-disclosure of relevant offenses raises questions related to truthfulness and character. (See 22 TAC ). NOTE: Orders of Non-Disclosure: Pursuant to Tex. Gov't Code (b), if you have criminal matters that are the subject of an order of non-disclosure you are not required to reveal those criminal matters on this form.