printable application

New Jersey Office of the Attorney GeneralDivision of Consumer AffairsNew Jersey Board of Nursing

124 Halsey Street, 6th Floor, P.O. Box 45010Newark, New Jersey 07101

(973) 504-6430www.NJConsumerAffairs.gov/nursing

Checklist for EndorsementLicensed Practical Nurse/ Registered Professional Nurse

NameofApplicant____________________________________________

SocialSecurityNumber______-_____-_____________ Ihavereadtheapplicationinstructions._______ OfficialApplicationforLicensurebyEndorsement(Pleasemakesureallofthe questionsareanswered.)_______ Original2”x2”colorpassportphoto.(Photocopiesarenotacceptable.)_______ Allrequiredsignaturesarecomplete.(Question6,page2,question7,page3, Affidavit,page7)_______ NotarizedAffidavit_______ Supportingcourtdocuments(ifapplicable,refertoquestions10-18onthe application,andquestion6ontheCertificationandAuthorizationform.)_______ Birthcertificate(Englishtranslation,ifapplicable.)_______ Immigrationdocumentation(ifapplicable,seepage2fordetails.)_______ Namechangecertificates(ifapplicable)_______ CertificationandAuthorizationFormforaCriminalHistoryBackgroundCheck (Makesureyousignanddatepage2.)_______ NewJerseyfingerprintcard(black,ifapplicable)_______ F.B.I.fingerprintcard(blue,ifapplicable)_______ MorphoTrustuniversalform(boxes1-18arecompleted,ifapplicable)_______ Ihavearrangedforlicenseverificationstobesentforallotherstatesoflicensure. (IftheyarenotavailableonNursys.)_______ Allrequiredfeesareincluded(applicationandsurchargefees($200.00),made payabletotheNewJerseyBoardofNursing;fingerprintingfeemadepayableto MorphoTrust,ifapplicable).

I have completed all of the checklist items above. ____________________________________________ (SignatureofApplicant)



(973) 504-6430www.njconsumeraffairs.gov/nur/Pages/default.aspx

INSTRUCTIONS FOR LICENSURE BY ENDORSEMENT IN NEW JERSEY

Please read the following information carefully before completing a paper application forlicensurebyendorsement.

If you previously held a nursing license in New Jersey, DO NOT complete an endorsementapplication.Youmustcontact theRenewal/ReinstatementDepartment inorder tocomplete theApplicationforReinstatement.

1. Checkthetypeoflicenseforwhichyouareapplying.AnswerALLofthequestions.

2. Attachaclear,full-faceoriginalpassportphotograph(2”x2”)ofyourheadandshoulders takenwithinthepastsixmonths.Signyournameonthebackofthepicture.(Photocopies andselfiesarenotacceptable.)

3. Completetheapplicationandsignitinthepresenceofanotarypublic.(Questions6,page 2,and7,page3,andtheAffidavit,Page7).

4. IfyouareaU.S.-borncitizen,pleasesubmitacopyofyourbirthcertificateorU.S.passport.

5. IfyouareanaturalizedU.S.citizen,pleasesubmitacopyofyourU.S.passportorcertificate ofnaturalization.

6. Ifyouarealegalalienorotherimmigrationstatus,pleasesubmityourUSCISimmigration documents.(Submitacopyofboththefrontandthebackofyourcard.)

7. Submitproofofalegalnamechange(i.e.,marriagelicense,divorcedecree,courtorder,if applicable)ifyournamediffersfromthatonyourbirthcertificate.

8. Complete the Certification andAuthorization form for a criminal history background check.

9. If you live outside the metropolitan New Jersey area, please go to: www.njconsumeraffairs.gov/nur/Pages/Fingerprint-Request.aspx and request fingerprint cards. Complete theMorpho Trust universal form and two (2) fingerprint cards, one black (New Jersey), and one blue (F.B.I.). Submit a check or money order in the amountof$58.68madepayabletoMorphoTrust.

10.If you live in the metropolitan New Jersey area, you will receive digital fingerprint informationviaregularmail.Pleasescheduleyourappointmentassoonaspossible.

11.Submitcriminalhistorydocuments(ifapplicable).

12.Providewrittenverificationoflicensureingoodstandingfromthestateinwhichyouwere originallylicensed,orarecurrentlylicensed,andfromeverystateinwhichyouhaveever been licensed.Theverification shall be forwardeddirectly to theNewJerseyBoardof Nursingfromtheapplicablestateboard(s),ifthosestate(s)arenotlistedontheNURSYS LicenseVerificationForm.

13.Submitapersonalcheckormoneyorderintheamountof$200.00madepayabletothe NewJerseyBoardofNursing.($120.00licensefee,$75.00nonrefundableapplicationfee, and$5.00mandatorynonrefundableAlternativetoDisciplinefee.)

14.Submitthecompleted“ChecklistforEndorsement,”withyoursignatureonthebottom.

ONLINE APPLICATION INSTRUCTIONS

1. Go to www.njconsumeraffairs.gov/Pages/onlinelicenses.aspx and submit an online applicationwithpaymentmadebycreditcard.($120.00licensefee,$75.00nonrefundable applicationfee,and$5.00mandatorynonrefundableAlternativetoDisciplinefee.)Print your receipt.

2. Submitaclear,full-faceoriginalpassportphotograph(2”x2”)ofyourheadandshoulders takenwithinthepastsixmonths.Signyournameonthebackofthepicture.(Photocopies andselfiesarenotacceptable.)

3. IfyouareaU.S.-borncitizen,pleasesubmitacopyofyourbirthcertificateorU.S.passport.

4. IfyouareanaturalizedU.S.citizen,pleasesubmitacopyofyourU.S.passportorcertificate ofnaturalization.

5. Ifyouarealegalalienorotherimmigrationstatus,pleasesubmityourUSCISimmigration documents.(Submitacopyofboththefrontandthebackofyourcard.)

6. Submitproofofalegalnamechange(i.e.,marriagelicense,divorcedecree,courtorder,if applicable)ifyournamediffersfromthatonyourbirthcertificate.

7. CarefullyreadandchecktheattestationattheendoftheapplicationgrantingtheBoard authorizationtoconductacriminalhistorybackgroundcheck.

8. If you live outside the metropolitan New Jersey area, please go to: www.njconsumeraffairs.gov/nur/Pages/Fingerprint-Request.aspx and request fingerprint cards. Complete the Morpho Trust universal form and two (2) fingerprint cards, oneblack (New Jersey), andoneblue (F.B.I.). Submit a checkormoneyorder in the amountof$58.68madepayabletoMorphoTrust.

9. If you live in the metropolitan New Jersey area, you will receive digital fingerprint informationviaregularmail.Pleasescheduleyourappointmentassoonaspossible.

10.Submitcriminalhistorydocuments(ifapplicable).

11.Providewrittenverificationoflicensureingoodstandingfromthestateinwhichyouwere originallylicensed,orarecurrentlylicensed,andfromeverystateinwhichyouhaveever beenlicensed.TheverificationmustbeforwardeddirectlytotheNewJerseyBoardof Nursingfromtheapplicablestateboard(s),ifthosestate(s)arenotlistedontheNURSYS LicenseVerificationForm.

12.Submitacopyofyourreceipt,signedatthebottom.

GENERAL INFORMATION

Wewillmakeeveryefforttoprocessyourapplicationinatimelymanner.However,theprocesswillbedelayediftheapplicationisincompleteorifanyoftherequireddocumentationhasnotbeensubmitted.Please note thattheBoardofNursingdoesnotissueatemporarylicense.

Ifyouchangeyournameand/oraddressaftersubmittinganapplicationforlicensure,youmustnotifytheBoardinwritingimmediatelyinordertoreceiveimportantinformation.

ItistheresponsibilityoftheapplicanttoensurethatallofthedocumentationrequiredtosubmitacompletedapplicationhasbeenreceivedbytheBoardinatimelyfashion(includinginformationfromanotherstate).Informationonthestatusofthelicensure-endorsementfilewillbegiventotheapplicantONLY.

Any incomplete applicationwhichhas remained inactive for six (6)monthswill be destroyedin accordancewith theDivision ofConsumerAffairs’ record retention plan.To reactivate theapplicationprocess,acompletelynewapplicationandfeewillberequired.

EffectiveJuly1,2008,a$5.00surchargefeefortheAlternative-toDisciplineprogrammustbepaid.

LICENSED PRACTICAL NURSE

Attendanceinorsuccessfulcompletionofaprofessionalnursingprogramshallnotserveasanequivalentorsubstitutedqualificationforthepracticalnursingeducationrequirement(N.J.A.C.13:37-4.1(b)).

NURSING PRACTICE ACT

It is theapplicant’s responsibility tokeepcurrenton the lawspertaining tohisorherpractice,the algorithm for determining the scope of nursing practice and the delegation of treatmentresponsibilitiesastheselawsaresubjecttochange.PleasereviewthestatutesandregulationsontheBoard’swebsitebecause the regulations are revisedoccasionally. (www.njconsumeraffairs.gov/nur/Pages/regulations.aspx)

Endorsement



(973) 504-6430

Official Application for Licensure by Endorsement

Date:_______________________________

Pleaseencloseanendorsementapplicationfilingfeeof$75.00,alicensecertificatefeeof$120.00anda$5.00surchargefee(foratotalof$200.00)intheformofacheckormoneyordermadeouttotheStateofNewJersey.(Applicantsshouldunderstandthatifthefeesarepaidwithapersonalcheck,andthecheckisreturnedbythebankduetoinsufficientfunds,thenextstepinthelicensureorcertificationprocesswillbedelayeduntilthefeesarepaid.).The$75.00fee,whichcoverstheapplicationonly,andthe$5.00surchargefeewillnot berefundedorheldover.Onlythelicensecertificatefeeof$120.00isrefundableifyouaredeterminedtobeineligibleforlicensureorcertification.

TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without theirconsent.However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponsetootherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddressofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureofyourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleasedtothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.

InformationthatyouprovideonthisapplicationmaybesubjecttopublicdisclosureasrequiredbytheOpenPublicRecordsAct(OPRA).

Please print clearly. You must answer all of the questions on this application.

Personal Information Dateofbirth:_________________________ MonthDayYear

Placeofbirth:________________________ CityState

Mr.1. Name Mrs.________________________________________________________________ (_______________________) Ms. Lastname Firstname Middleinitial Maidenname

2. Address

Home:______________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

_____________________________________ ___________________________________ Telephonenumber(includeareacode) E-mailaddress

Business:____________________________________________________________________________________________ Nameofcompany Telephonenumber(includeareacode)

____________________________________________________________________________________________ Street City State ZIPcode County

Mailing: ____________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

Applicant: Checklicensetypeforwhichyouareapplying: RegisteredProfessionalNurse LicensedPracticalNurse

Board Staff:DatereceivedbytheBoard:_________________________

LicenseorCertificatenumber:_________________________

Attachaclear,full-facepassportphotograph(2˝x2˝)ofyourheadandshoulders,takenwithinthe past sixmonths,with yournameprintedon thebackof thephoto.A photo is requiredwith eachapplication.

Donot use staples to attach thephoto.

Endorsement

3. SocialSecurityNumber YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosowillresultindenial/nonrenewalof licensureorcertification.

*SocialSecurityNumber: __________ -____________ -___________

*PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildSupportEnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommitteeisrequiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovideyourSocialSecuritynumberto:

a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;

b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest;and

c. theNational PractitionerDataBank and theH.I.P.DataBank,when reporting adverse actions relating to health care professionals.

4. Citizenship/ImmigrationStatus

FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcertificatestoU.S.citizensorqualifiedaliens. Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot aU.S.citizen,attacha copy of your alien registration card(frontandback)orotherdocumentationissuedbytheofficeofU.S. CitizenshipandImmigrationServices(USCIS).

U.S.citizen AlienlawfullyadmittedforpermanentresidenceinU.S. Otherimmigrationstatus

Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe USCISat:1-800-375-5283.

IfyouarenotaU.S.citizen,attacha copy of your alien registration card(frontandback)orotherdocumentationissuedbythe officeofU.S.CitizenshipandImmigrationServices(USCIS).

5. StudentLoan

Areyouindefaultinregardtoanystudentloanobligation(s)? Yes No

If“Yes,”youmustobtaindocumentaryevidencethatyouhavereachedanarrangementwiththebankorwiththeentitythatissued yourstudentloan,fortheeventualrepaymentoftheloan.Youwillnotbeabletoobtainalicenseorcertificateunlessyouprovidethe requireddocumentsconcerningtheplanforrepaymentofyourstudentloan.

6. ChildSupport(You must answer a, b, c and d.)

Please certify, under penalty of perjury, the following:

a. Doyoucurrentlyhaveachild-supportobligation? Yes No

(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No

(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No

b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No

c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No

d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No

InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsa(1)throughdwillresult inadenialoflicensureorcertification.Furthermore,anyfalsecertificationoftheabovemaysubjectyoutoapenalty,including,butnotlimitedto,immediaterevocationorsuspensionoflicensureorcertification.

___________________________________ ___________________________________ ________________________ Applicant’sname(pleaseprint) Applicant’ssignature Date

-2-

Fullname:___________________________________________________________________________________________________

Endorsement7. MedicalConditionsQuestions Questionsathroughfpertaintomedicalconditionsanduseofchemicalsubstances.Pleasereadthedefinitionscarefully.Your

responseswillbetreatedconfidentiallyandretainedseparately.Pleasebeawarethatyouhavetherighttoelectnottoanswerthoseportionsofthefollowingquestionswhichinquireastotheillegaluseofcontrolleddangeroussubstancesoractivityifyouhavereasonablecausetobelievethatansweringmayexposeyoutothepossibilityofcriminalprosecution.Inthatevent,youmayasserttheFifthAmendmentprivilegeagainstself-incrimination.AnyclaimofFifthAmendmentprivilegemustbemadeingoodfaith.IfyouchoosetoasserttheFifthAmendment,youmustdosoinwriting.Youmustfullyrespondtoallotherquestionsontheapplication.YourapplicationforlicensureorcertificationwillbeprocessedifyouclaimtheFifthAmendmentprivilegeagainstself-incrimination.Youshouldbeaware,however,thatyoumaylaterbedirectedbytheAttorneyGeneraltoansweraquestionthatyouhaverefusedtoansweronthebasisoftheFifthAmendment,providedthattheAttorneyGeneralfirstgrantsyouimmunityaffordedbystatutorylaw.(N.J.S.A.45:1-20.)

Forthepurposesofthesequestions,thefollowingphrasesorwordshavethefollowingmeanings:

“Ability to practice as a registered professional nurse or a licensed practical nurse”istobeconstruedtoincludeallofthefollowing:

a. The cognitive capacity to exercise the reasonable judgments of a registered professional nurse or a licensedpracticalnurse,andtolearnandkeepabreastofprofessionaldevelopments;and

b. Theabilitytocommunicatethosejudgmentsandrelatedinformationtopatientsandotherinterestedparties,withorwithouttheuseofaidsordevices,suchasvoiceamplifiers;and

c. The physical capability to perform the duties of a registered professional nurse or a licensed practical nurse,withorwithouttheuseofaidsordevices,suchascorrectivelensesorhearingaids.

“Medical Condition”includesphysiological,mentalorpsychologicalconditionsordisorders,suchas,butnotlimitedtoorthopedic,visual,speechandhearingimpairments,cerebralpalsy,epilepsy,musculardystrophy,multiplesclerosis,cancer,heartdisease,diabetes,mentalretardation,emotionalormentalillness,specificlearningdisabilities,H.I.V.disease,tuberculosis,drugaddictionandalcoholism.

“Chemical substance” is tobeconstrued to includealcohol,drugsormedications, including those takenpursuant toavalidprescriptionforlegitimatemedicalpurposesandinaccordancewiththeprescriber’sdirection,aswellasthoseusedillegally.

“Currently”doesnotmeanonthedayof,orevenintheweeksormonthsprecedingthecompletionofthisapplication.Rather,itmeansrecentlyenoughsothattheuseofdrugsmayhaveanongoingimpactonone’sfunctioningasalicensee,orwithintheprevioustwoyears.

“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g.heroinorcocaine)aswellastheuseofcontrolleddangeroussubstanceswhicharenotobtainedpursuanttoavalidprescriptionornottakeninaccordancewiththedirectionsofalicensedhealthcarepractitioner.

a. Doyouhaveamedicalconditionwhichinanywayimpairsorlimitsyourabilitytopracticeyourprofessionwithreasonableskillandsafety? Yes No

b. Are the limitationsor impairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseyoureceiveongoingtreatment(withorwithoutmedications)orparticipateinamonitoringprogram**?

Yes No Notapplicablec. Arethelimitationsorimpairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseofthefieldofpractice,

thesettingormannerinwhichyouhavechosentopractice? Yes No Notapplicabled. Doesyouruseofchemicalsubstance(s)inanywayimpairorlimityourabilitytopracticeyourprofessionwithreasonableskill

andsafety? Yes No Notapplicablee. Haveyoueverbeendiagnosedashavingorhaveyoueverbeentreatedforpedophilia,exhibitionismorvoyeurism?

Yes Nof. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances?(Recallthat“currently”isdefinedas“within

thelasttwoyears.”) Yes No Ifyouanswered“Yes” toquestion f,areyoucurrentlyparticipating inasupervised rehabilitationprogramorprofessional

assistanceprogramwhichmonitorsyouinordertoassurethatyouarenotengagingintheillegaluseofcontrolleddangeroussubstances? Yes No

** Ifyoureceivesuchongoingtreatmentorparticipate insuchamonitoringprogram, theBoardwillmakean individualizedassessmentofthenature,theseverityandthedurationoftherisksassociatedwithanongoingmedicalconditionsoastodeterminewhetheranunrestrictedlicenseorcertificateshouldbeissued,whetherconditionsshouldbeimposedorwhetheryouarenoteligibleforlicensureorcertification.

____________________________________________________ ___________________________________ Applicant’ssignature Date

-3-Fullname:___________________________________________________________________________________________________

Endorsement8. Haveyoueverchangedyourname? Yes No

If“Yes,”pleasesubmitwiththisapplicationacopyofthemarriagecertificate,divorcedecreeorcourtorder.

9. OtherLicenses:

a.Doyoucurrentlyhold,orhaveyoueverheld,aprofessionallicenseorcertificateofanykindinNewJersey? Yes No

b. Do you currently hold, or have you ever held, a professional license or certificate of any kind in any other state, the DistrictofColumbiaorinanyotherjurisdiction? Yes No

Ifyouanswered“Yes”toquestion9aor9b,foreachlicenseorcertificateheld,providethedate(s)heldandthelicensenumber(s).Ifthelicense orcertificatewasissuedunderadifferentname,pleaseprovidethatname.______________________________________________LastnameFirstnameMiddleinitial

______________________ _______________________ ____________________________ ____________________ TypeoflicenseorcertificatebyStateBoardExam Number Stateorjurisdictionthatissuedthelicenseorcertificate Dateissued/expired

_____________________ _______________________ ____________________________ ____________________ TypeoflicenseorcertificatebyEndorsement Number Stateorjurisdictionthatissuedthelicenseorcertificate Dateissued/expired




10. HaveyoueverbeendisciplinedordeniedaprofessionallicenseorcertificateofanykindinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

11. Haveyoueverhadaprofessionallicenseorcertificateofanytypesuspended,revokedorsurrenderedinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

12. Hasanyaction(includingtheassessmentoffinesorotherpenalties)everbeentakenagainstyourprofessionalpracticebyanyagencyorcertificationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

13. HaveyoueverbeennamedasadefendantinanylitigationrelatedtothepracticeofnursingorotherprofessionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

14.Have you ever been summoned; arrested; taken into custody; indicted; tried; chargedwith; admitted into pre-trial intervention(P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicleviolationssuchasdrivingwhileimpairedorintoxicatedmustbe.) Yes No

15. Haveyoueverbeenconvictedofanycrimeoroffenseunderanycircumstances?Thisincludes,butisnotlimitedto,apleaofguilty,nonvult,nolocontendere,nocontest,orafindingofguiltbyajudgeorjury. Yes No

If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a completeexplanation.(Attachadditionalsheetsofpapertothisapplication.)

16. AreyouawareofanyinvestigationpendingagainstaprofessionallicenseorcertificateissuedtoyoubyaprofessionalboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

17. Are thereanycriminalchargesnowpendingagainstyou inNewJersey, anyother state, theDistrictofColumbiaor inanyotherjurisdiction? Yes No

18. Haveyoueverbeensanctionedbyor isanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgrouprelatedtothepracticeofnursingorotherprofessionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

Iftheanswertoanyoftheabovequestions,numbers10through18,is“Yes,”provideacompleteexplanationofthecircumstancesleadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.

-4-Fullname:___________________________________________________________________________________________________

Endorsement

EducationIn the spacesbelow,giveanaccurate recordofyoureducationalpreparation.Besure tocomplete itemsA-Dforeachschool.Useadditionalsheetsofpaperifnecessary.

A B C D

A B C D

A. Name of schools attended and locations B. Number

of Years Attended

C. Attendance

Entrance date Leaving date D. Title of diploma or degree

obtained*

Postsecondary School(s) including basic nursing education programs

________________________________________________ Name of school Program major

_____________________________ ________________ City State/Country





High School or Primary School

________________________________________________ Name of school


________________________________________________ Name of school


_____ / ____

Month Year_____ / ____

Month Year

_____ / ____


Month Year

Check appropriate type:

Graduatediploma

Graduateequivalency diploma

_____ / ____


Month Year

_____ / ____


Month Year

_____ / ____


Month Year

* Note: If your professional school was located outside the U.S., and you have a copy of your degree/diploma in the original language, attach a copy to this form.

-5-Fullname:___________________________________________________________________________________________________

A. Name of schools attended and locations B. Number

of Years Attended

C. Attendance

Entrance date Leaving date

D. Title of diploma or degree obtained*

Check appropriate type:

L.P.N.

Certificate

Diploma

R.N.

Diploma

Associate’sDegree

Bachelor’sDegree

EndorsementNursing Work ExperienceDonotincludeacurriculumvitaeoraresume.Neitherwillmeettheregulatoryrequirementsforcompletingthisapplication.

1. Listthenursingexperienceyouhaveacquired.Providetheinformationaboutyourcurrentemploymentfirst.Useadditionalsheetsofpaperifnecessary.Ifyoudonothaveanyworkexperience,pleaseleavethissectionblank.

(a) Employer:___________________________________________________________________________________________

Address:____________________________________________________________________________________________ Streetaddress City State ZIPcode

Telephonenumber:__________________________________ (includeareacode)

Titleofyourposition:__________________________________________________ Hoursperweek:__________________

From____________________________________________ to________________________________________________ Month Year Month Year

Immediatesupervisor’snameandtitle:____________________________________________________________________

(b) Employer:___________________________________________________________________________________________






(c) Employer:___________________________________________________________________________________________






Important Information

1. Youmustbeatleast18yearsoldtoapplyforlicensurebyendorsement.

2. VerificationformsfromeverystateorjurisdictioninwhichyouhavebeenlicensedorcertifiedmustbesentdirectlytotheNewJerseyBoardofNursingbytheboardofnursingineachstateorjurisdiction.

-6-

Fullname:___________________________________________________________________________________________________

Endorsement

AffidAvit

This affidavit is to be executed by the applicant before a notary public:

Stateof:__________________________________________________

Countyof:________________________________________________

I, ________________________________________________ , inmaking this application to theNew JerseyBoard ofNursing forlicensureorcertificationundertheprovisionsofTitle45oftheGeneralStatutesofNewJerseyandtheRulesoftheNewJerseyBoardofNursing,swear(oraffirm)thatIamtheapplicantandthatallinformationprovidedinconnectionwiththisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmaybedeemedsufficienttodenylicensureorcertificationortowithholdrenewaloforsuspendorrevokealicenseorcertificateissuedbytheBoard.

Ifurtherswear(oraffirm)thatIhavereadN.J.S.A.45:11-23etseq.,togetherwiththeRulesandRegulationsoftheNewJerseyBoardofNursing,N.J.A.C.13:37-1.1through13:37-14.17,andfullyunderstandthatinreceivinglicensureorcertificationfromtheBoard,Ibindmyselftobegovernedbythem.

Furthermore, I voluntarily consent to a thorough investigation ofmy present and past employment and other activities forthepurposeofverifyingmyqualificationsforlicensureorcertification.Ifurtherauthorizeallinstitutions,employers,agenciesandallgovernmentalagenciesandinstrumentalities(local,state,federalorforeign)toreleaseanyinformation,filesorrecordsrequestedbytheBoard.

__________________________________________________ Applicant’ssignature

Swornandsubscribedtobeforemethis__________________

dayof ____________________________ ,______________ MonthYear

__________________________________________________ NameofNotaryPublic(pleaseprint)

Affix Seal Here

__________________________________________________ SignatureofNotaryPublic

} ss.

-7-

Fullname:___________________________________________________________________________________________________



(973) 504-6430www.NJConsumerAffairs.gov/nursing

DearApplicant:

TheDivisionofConsumerAffairs isrequiredtoconductcriminalhistoryrecordbackgroundchecksonallhealthcareprofessionalsprior to the issuanceof an initial licenseorother authorization topractice(N.J.S.A.45:1-28etseq.).

InorderfortheDivisiontoconductacriminalhistoryrecordbackgroundcheck,youmustcompletetheenclosedCertificationandAuthorizationformandreturnittothemailingaddressabove.

(In-State Applicants)UponreceiptofthecompletedCertificationandAuthorizationform,theBoardwillforwardyourinformationabouthow to scheduleanappointmentwithMorphoTrust, Inc., tohaveyourfingerprints electronicallyrecorded.The fee for the fingerprinting and background check is $62.69. The fee must be paid to MorphoTrust, at the time of scheduling your appointment for fingerprinting. The following formsofpaymentareaccepted:Visa,MasterCard,orprepaiddebitcards,orelectronicdebit(ACH)fromacheckingaccount.Accountswillbedebitedimmediately.

(Out-of-State Applicants)Upon receipt of the completed Certification andAuthorization form, the Board will forward to youinformationtohaveyourfingerprintsrecordedontotraditionalfingerprintcards.Out-of-stateapplicantsmusthavetheirfingerprintsrecorded,onthecardsweprovide,bytheirlocalpolicedepartment,bytheirstatepolicedepartmentorbytheirlocallawenforcementagency.Youmustreturnthefingerprintcards,completedIdentoGouniversalfingerprintingform,theNewJerseyStatePolice-ApplicantIdentificationFormthatwascompletedbytheagencytakingyourfingerprints,andthe$58.68feeforthefingerprintingandbackgroundchecktotheBoardorCommittee.The $58.68 should be in the form of a check or money order made payable to MorphoTrust. Checks or money orders older than 60 days will be returned to the applicant.

IfyoufailtocompleteandreturntheCertificationandAuthorizationform,yourapplicationforlicensureorcertificationwillnotbeprocessedandyourapplicationwillbeconsideredabandoned.

TheNewJerseyBoardofNursing

Endorsement

New Jersey Office of the Attorney General

Division of Consumer AffairsNew Jersey Board of Nursing

P.O. Box 45010Newark, New Jersey 07101

(973) 504-6430

CertifiCAtion And AuthorizAtion form for A CriminAl history BACkground CheCk

Directions:Answerallofthequestionsonthisform.

1. Name _________________________________________________________ ( ________________________) LastFirstMiddle MaidenName

2. Address___________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode

3. Dateofbirth____/____/____ Sex: Male FemaleMonthDayYear

4. SocialSecuritynumber_________/_____ / ________

5. HaveyoucompletedthefingerprintingprocessforanyBoard or Committee of the New Jersey Division of Consumer AffairssinceNovember2003? Yes No

If“No,”youwillreceiveaseparatemailingfromtheBoardorCommitteeregardingthecriminalhistoryrecordbackgroundcheckprocess.Nopaymentisnecessaryasofnow.

If“Yes,”pleaseprovidethefollowinginformationandfollowtheinstructionsoutlinedbelow:

_______________________________________________ _______________________________________________ BoardorcommitteerequiringthefingerprintingMonthandyearyouwerefingerprinted

If youwere fingerprinted afterNovember 2003 as part of the criminal history background process for licensure orcertificationbyanyotherBoard or Committee of the New Jersey Division of Consumer Affairs (abackgroundcheckconductedfortheDepartmentofEducation,anotherstateagencyoranotherstatedoesnotapply)youwillnotberequiredtobefingerprintedasecondtime.However,theDivisionmustperformacriminalhistorybackgroundcheckeachtimeyouapplyforlicensureorcertification.The fee for this service is $17.50. PaymentshouldbemadeintheformofacheckormoneyorderpayabletotheStateofNewJerseyandshouldaccompanyyourapplicationpacket.

6. Haveyoueverbeenarrestedand/orconvictedofacrimeoroffense?(Minortrafficoffensessuchasaparkingorspeedingviolationsneednotbelisted.) Yes No

Every such conviction on record must be disclosed. Atruecopyofeverypolicereport,judgmentofconviction,sentencing orderandterminationofprobationorder,ifapplicable,must besubmittedwiththisform.Anydocuments(includingemployer orsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust besubmitted withthisform.Failure to follow these instructions may result in the denial of an initial application. Note: Copiesofjudgments,sentencingandterminationofprobationordersmaybeobtainedfromtheclerkofthecounty wherethoseorders,disposingoftheconviction,wereissuedandfiled. Your continuing responsibility to disclose convictions of crimes or offenses:Youmust notifytheBoardorCommittee withinfive(5)businessdaysifyouareconvictedofanycrimesoroffensesafterthisformhasbeencompleted.

Continuationonthereverseside➨

Mr. Mrs. Ms.

BoardorCommittee________________________

Official Use Only

Resubmit________________________

Official Use OnlyDualLicense

LicenseType1________________________

Applicant’sNumber________________________

LicenseType2________________________

Applicant’sNumber________________________

CertifiCAtion

I, ______________________________________________, in making this application to the Board or Committee forcertification or licensure, certify that I am the applicant and that all of the information provided in connectionwith thisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmaybedeemedsufficienttodenycertificationorlicensureortowithholdrenewaloforsuspendorrevokeacertificateorlicenseissuedbytheBoardorCommittee.

I voluntarily consent to a thorough investigation ofmy present and past employment and other activities for the purposeof verifyingmyqualifications for certification or licensure. I further authorize all institutions, employers, agencies and allgovernmental agencies and instrumentalities (local, state, federal or foreign) to release any information, files or recordsrequestedbytheBoardorCommittee.

Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymearewillfullyfalse,Iamsubjecttopunishment.

__________________________________________________________ _________________________________ SignatureofapplicantDate

Rev.10/1/16

Endorsement



(973) 504-6430

License Verification Request Directions to applicant: CompleteonlythetopportionofthislicenseverificationformandforwardittotheBoardofNursinginthestate(s)inwhichyouareorhavebeenlicensed.Theboard(s)shouldcompletetheformandreturnittotheNewJerseyBoardofNursing.Note:Beadvisedthattheboard(s)completingtheformmaychargeafeeforlicenseverification.Pleasecalltheboard(s)tocheckonfeesforlicenseverificationpriortosubmittingthisform.IfanystateinwhichyouarelicensedisamemberofNursys®,pleaseusetheNCSBNNursys®forminorderforustoreceiveyourverificationsfaster.(PleaseseethecompleteinstructionsontheNCSBNNursys®form.)

RegisteredNurse LicensedPracticalNurse Name:___________________________________________________________________________________ Firstname Middlename Lastname Maidenname,ifapplicable

Nameonoriginallicense:_________________________________ Telephonenumber:__________________ (includeareacode)

Currentaddress:____________________________________________________________________________ Street City State ZIP

Schoolofnursing:_________________________________ Location:________________________________ Yearofgraduation: ________________Licensenumber:_____________________ Yearissued: ____________

Directions to State Board of Nursing: This section is to be completed by the State Board of Nursing.* Please include this form with any verification or correspondence sent to the New Jersey Board of Nursing at the address above.

1. Licenseregistrationnumber:__________________________________ Date:____________________________

2. Didtheapplicantgraduatefromaboardaccreditedorapprovedschoolofnursing? Yes No3. StateBoardexaminationscores:(Iftheexamsweretakenpriorto1949,pleaselistthesubjectsandscores.) Score Series Score Series Medicalnursing Surgicalnursing Nursingofchildren Obstetricnursing Psychiatricnursing N.C.L.E.X.4. Waslicenseissuedby: StateBoardtestpoolexams? Yes No Score _____________ Series ______________ N.C.L.E.X.? Yes No Score _____________ Series ______________ Waiver? Yes NoDate Endorsement? Yes NoDate ______________________________5. Hasthislicenseeverbeenrevoked,suspendedorvoluntarilysurrendered? Yes No If“Yes,”pleaseprovideadescriptionofthecharge(s)andanyaction(s)takenandprovideacopyofany complaint,orderandvoluntarysurrenderdocument. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Icertifythatthestatementscontainedhereinaretruetothebestofmybelief, andIrecommendthisnurseforlicensureintheStateofNewJersey. Secretary______________________________________________________ State__________________________________________________________ Date__________________________________________________________

Official Seal

Endorsement

Alabama (334)242-4060

Alaska (907)269-8161

Arizona (602)331-8111

Arkansas (501)686-2700

CaliforniaRN (916)322-3350

CaliforniaPN (916)263-7800

Colorado (303)894-2430

Connecticut (860)509-7624

Delaware (302)739-4522

WashingtonDC (202)442-4380

Florida (904)858-6940

GeorgiaRN (912)207-1640

GeorgiaPN (912)207-1640

Hawaii (808)586-3000

Idaho (208)334-3110

Illinois (312)814-2715

Indiana (317)232-2960

Iowa (515)281-3255

Kansas (785)296-4929

Kentucky (502)329-7000

LouisianaRN (504)838-5332

LouisianaPN (504)838-5791

Maine (207)287-1133

Maryland (410)585-1900

Massachusetts (617)727-9961

Michigan (517)373-9102

Minnesota (612)617-2270

Mississippi (480)987-4188

Missouri (573)751-0681

Montana (406)444-2071

Nebraska (402)471-4376

Nevada (775)688-2620

NewHampshire (603)271-2323

NewJersey (973)504-6430

NewMexico (505)841-8340

NewYork (518)474-3843

NorthCarolina (919)782-3211

NorthDakota (701)328-9777

Ohio (614)466-3947

Oklahoma (405)962-1800

Oregon (503)731-4745

Pennsylvania (717)783-7142

RhodeIsland (401)222-2827

SouthCarolina (803)896-4550

SouthDakota (605)362-2760

Tennessee (615)532-5166

TexasRN (512)305-7400

TexasPN (512)305-8100

Utah (801)530-6628

Vermont (802)828-2396

Virginia (804)662-9909

WashingtonRN (360)236-4713

WashingtonPN (360)236-4713

WestVirginiaRN (304)558-3596

WestVirginiaPN (360)558-3572

Wyoming (307)777-7601

Outside Continental USA

AmericanSamoa (684)633-1222-206

In the United States

Guam 011(671)475-0251

N.MarianaIsland 01-670-234-8950 through8954

PuertoRico (787)725-8161(Only if NCLEX Exam was taken.)

VirginIsland (340)776-7397

License VerificationCheck Nursys website for participating Boards of Nursing. The website address to process your verification is: www.nursys.com . If the state(s) in which you are licensed is/are not a member of Nursys, please use the enclosed Verification Request Form. Juristictions that Participate in Nursys License Verification as of June 3, 2016.

ALAskA (Ak)AmeRICAN sAmoA (As) ARIzoNA (Az)ARkANsAs (AR)CoLoRAdo (Co)deLAwARe (de)dIsTRICT oF CoLumBIA (dC) FLoRIdA (FL) GeoRGIA (GA) GuAm (Gm) IdAho (Id)ILLINoIs (IL)INdIANA (IN) IowA (IA)keNTuCky (ky) LouIsIANA-RN mAINe (me)mARyLANd (md)mAssAChuseTTs (mA) mIChIGAN (mo)mINNesoTA (mN) mIssIssIPPI (ms) mIssouRI (mo)moNTANA (mT)

NeBRAskA (Ne)NeVAdA (NV) New hAmPshIRe (Nh)New JeRsey (NJ)New mexICo (Nm)New yoRk (Ny)NoRTh CARoLINA (NC) NoRTh dAkoTA (Nd)NoRTheRN mARIANA IsLANds ohIo (oh)oReGoN (oR) Rhode IsLANd (RI) souTh CARoLINA (sC) souTh dAkoTA (sd)TeNNessee (TN) TexAs (Tx)uTAh (uT)VeRmoNT (VT) VIRGIN IsLANds (VI) VIRGINIA (VA)wAshINGToN (wA) wesT VIRGINIA-PN (wV) wIsCoNsIN (wI)wyomING (wy)

states that do not participate in Nursys License Verification as of June 3, 2016.

ALABAmACALIFoRNIAkANsAsLouIsIANA-PNokLAhomAPeNNsyLVANIAwesT VIRGINIA-RNhAwAII-LPN/RN

printable application

Documents