APPLICATION FOR LICENSURE BY ENDORSEMENT WITH EXAMINATION/ TEMPORARY PRACTICE PERMIT

Transcription

1 PENNSYLVANIA STATE BOARD OF NURSING P.O. BOX 2649 HARRISBURG, PA (717) FAX (717) APPLICATION FOR LICENSURE BY ENDORSEMENT WITH EXAMINATION/ TEMPORARY PRACTICE PERMIT 1. SUBMIT A COMPLETED APPLICATION If yu hld r ever held a Pennsylvania nursing license yur PA license must be reactivated. DO NOT PROCEED with this applicatin unless yu are applying fr a different license type. If yu have passed the Natinal Cuncil Licensure Examinatin (NCLEX ) examinatin r the State Bard Test Pl Exam (SBTPE), yu cannt use this applicatin. Please see Applicatin fr Licensure by Endrsement. Use yur full legal name n the applicatin and list any ther prir names that may have been used. A change f address/name must be in writing and include: name, scial security number, ld address, new address, date f birth, signature and Pennsylvania nursing license number, if applicable. A name change will be made nly if cpies f fficial dcuments are included (marriage certificate, divrce decree, r curt rders). Licenses are nt frwardable. It is yur respnsibility t infrm the bard f an address change. Act 58 f 1997 mandates that gvernment agencies cllect scial security numbers. An applicatin cannt be prcessed withut a U.S. Scial Security Number r a cmpleted scial security waiver frm. 2. SUBMIT CHECK OR MONEY ORDER MADE PAYABLE TO COMMONWEALTH OF PA. THE CORRECT FEE IS $135.00, IF APPLYING ONLY FOR PERMANENT LICENSURE OR $ IF ALSO REQUESTING A TEMPORARY PRACTICE PERMIT. Fees can be cmbined and submitted with ne check r mney rder. D nt send cash. Charge cards are nt accepted. A check/mney rder drawn n a freign bank is nt acceptable unless there is an affiliated bank lcated in the U.S.A. and "US funds" are identified n the check/mney rder. The fee is nn-refundable and cvers the cst f evaluating the applicatin. Fllwing the initial perid f licensure, the license must be renewed every tw years. A prcessing fee f $20.00 will be charged fr a check r mney rder returned unpaid. Frms received withut the crrect fee cannt be evaluated and will be returned t the applicant. 3. VERIFICATION OF ORIGINAL LICENSE MUST BE SENT DIRECTLY TO THE PA BOARD OF NURSING FROM THE ORIGINAL LICENSING AUTHORITY WHERE YOU PASSED THE LICENSING EXAMINATION. The term riginal nursing license refers t the first nursing license btained in the United States, its territries r Canada by examinatin. Cntact yur riginal licensing authrity t determine the crrect methd f verificatin. A listing f Bards f Nursing can be lcated at Certain states use the Nursys verificatin website t verify licensure. Nursys is the nurse licensing database fr the Natinal Cuncil f State Bards f Nursing. It includes data frm all Member Bards that have prvided data t the Natinal Cuncil. An updated listing f the participating states can be fund n the Nursys website at If yur riginal license is in Canada r Puert Ric and yu have passed the NCLEX examinatin in anther state, request verificatin frm yur riginal licensing authrity as well as verificatin frm the state where yu passed NCLEX. Pennsylvania requires that all applicants pass Natinal Cuncil Licensure Examinatin (NCLEX) r State Bard Test Pl Exam (SBTPE). An applicant must have cmpleted an apprved registered nursing prgram t be eligible fr Registered Nurse licensure r an apprved practical nursing prgram t be eligible fr Practical Nurse licensure. Cmpleting part f a registered nursing prgram des nt meet requirements t be licensed as a Practical Nurse in Pennsylvania. Prvide the entire crrect name f the schl f nursing cmpleted s that fficial dcuments can be matched. The term schl f nursing refers t the name f the institutin, schl, cllege r university where yu cmpleted the educatin which qualified yu fr yur riginal nursing license. - Instructins Page 1 f 2 revised TEX -

2 4. APPLICATION PROCESSING The time fr prcessing an applicatin depends n the receipt f crrect cmplete infrmatin and fee(s). The State Bard f Nursing ffice is pen Mnday thrugh Friday 8:30 5:00 EST and bserves fficial state hlidays and clsings. Our gal is t prcess yur applicatin as quickly as pssible. Repeated phne calls interrupt and delay the time we need t review dcuments. Please check the Pennsylvania Bard f Nursing verificatin website t see if a license has been issued at Mail is prcessed in the rder it is received. All licenses/permits are mailed t the address n recrd. Licenses/permits are nt issued n-site. A Temprary Practice Permit is valid fr ne year frm the date f issue, r until a permanent license is issued r denied. A current and valid permit may be extended fr ne year by applying t the State Bard f Nursing. The applicatin fr extensin can be btained frm the Bard s web page It is the respnsibility f the applicant t ensure the State Bard f Nursing receives all required infrmatin. 5. CONTACT INFORMATION If yu need t cntact the State Bard f Nursing ffice please d s by fax, mail r phne. If yur call is transferred t vice mail, be sure t leave yur name, scial security number and cmplete phne number including area cde. The FAX message is available nly fr materials that d nt require fficial seals and signatures. The cmpleted applicatin cannt be faxed. T request acknwledgment f the receipt f an applicatin, send it "certified mail - return receipt requested." N ther acknwledgment will be made. The address fr express mail is: 2601 N. 3 rd Street, Harrisburg, PA General infrmatin abut the State Bard f Nursing can be fund n the Department f State s web site at 6. NURSES EDUCATED IN CANADA, PUERTO RICO OR A UNITED STATES TERRITORY WHO HAVE NOT PASSED NCLEX If yu are applying fr licensure in Pennsylvania and yur basic nursing prgram was lcated in Canada, Puert Ric r a United States Territry, request translated transcripts t be sent directly frm yur schl f nursing t the Pennsylvania State Bard f Nursing. A wrd-fr-wrd English translatin must accmpany the transcript, if it is nt in English. A Certificate f Accuracy must be typed r written at the end f the translatin and must be signed by the translatr. Yu will be required t pass NCLEX, if yu have nt dne s. Request verificatin f licensure frm yur riginal licensing authrity. Refer t the enclsed NCLEX bulletin r cntact NCLEX fr infrmatin regarding the licensing examinatin at Once yur PA licensure applicatin has been evaluated and apprved fr testing by the Pennsylvania Bard and the NCLEX registratin frm and fee have been received by Pearsn Vue, yu will receive an authrizatin t test (ATT). - Instructins Page 2 f 2 revised TEX -

3 6. ENGLISH PROFICIENCY (Refer t Sectins 21.7b12 and b2 f the Bards regulatins requiring English Prficiency) If yu are applying fr a Temprary Practice Permit as a currently licensed nurse and yur basic nursing prgram was nt cnducted in English, yu must prvide the Bard with evidence f English prficiency by ne f the fllwing: Achieve a passing scre f 83 r higher n the Test f English as a Freign Language Internet based Testing (TOEFL ibt) Achieve a passing scre f 540 r higher n the Test f English as a Freign Language Paper-based Testing (TOEFL PBT) Achieve a passing scre f 207 r higher n the Test f English as a Freign Language Cmputer-based Testing (TOEFL CBT) Achieve a passing scre f 6.5 r higher n all mdules f the Internatinal English Language Test System (IELTS), ffered in paper r cmputer base. Achieve a passing scre f 725 r higher n the Test f English fr Internatinal Cmmunicatin (TOEIC) Test scres must be sent directly t the Bard frm the testing agency. Cpies are nt acceptable. Please nte, the Educatinal Testing Service (ETS) has a time limit n keeping the scring infrmatin. After a tw year time frame the ETS will n lnger verify the scres. The Language Prficiency Industry has set this tw year validity perid. Address fr: Educatin Testing Service (ETS) Rsedale Rad Princetn, NJ USA Tel: Fax: Test f English as Freign Language (TOEFL) Educatinal Testing Service PO Bx tefl@ets.rg Test f English fr Internatinal Cmmunicatin Service Internatinal (TOEIC) TOEIC Testing Prgram Educatinal Testing Service Rsedale Rad Princetn, NJ Phne: Fax: TOEIC@ets.rg Internatinal English Language Test System (IELTS) At this site, select the IELTS administratin center clsest t yu where yu intend t take the IELTS examinatin. IELTS is administered by: British Cuncil IDP: IELTS Australia University f Cambridge ESOLS examinatins - Applicatin Page 1 f 3 revised TEX

4 FOR OFFICE USE License # Permit # Receipt # TEX Pennsylvania State Bard f Nursing P.O. Bx 2649 Harrisburg, PA (717) st-nurse@state.pa.us APPLICATION FOR LICENSURE BY ENDORSEMENT WITH EXAMINATION /TEMPORARY PRACTICE PERMIT Check ALL bxes that apply. T be eligible fr a temprary permit, yu must submit an applicatin fr permanent licensure. If applying fr temprary practice permit, list the required infrmatin regarding a valid, current license (State, License # and Expiratin Date). Registered Nurse License ($135) Registered Nurse Permit ($35) Practical Nurse License ($135) Practical Nurse Permit ($35) State License # Expiratin Date ENCLOSE CHECK OR MONEY ORDER PAYABLE TO Cmmnwealth f PA 1. Name: Last First Middle Maiden Name 2. Other Names: 3. Daytime Phne #: Between 8:30 5:00 EST Address: 4. Mailing Address: Street City / State /Zip Cde Scial Security# Date f Birth / / If yu d nt currently have a scial security number, cmplete the MM DD YYYY enclsed waiver frm. Original Licensing Authrity: State/Prvince/Territry Expiratin Date License # ALL ther Nursing Licenses that yu currently hld r have ever held. Check bx and prvide license number and expiratin date: 8. AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE Basic Nursing Educatin Prgram: Type f Prgram: RN PN Name as it appears n Transcripts: NV NH NJ NM NY NC ND OH OK OR PA RI SC SD SEE INSTRUCTIONS TN TX UT VT VA WA WV WI WY Any Cuntry r Territry Name f Schl: Date f Cmpletin (Mnth, Year) City, State, Cuntry f Schl: Was this nursing educatin prgram cnducted in English? Yes N - Applicatin Page 1 f 3 revised TEX

5 APPLICANT NAME: PRINT FULL NAME SS# Are yu requesting special accmmdatins? Yes N If yes, submit a cmpleted Request fr Accmmdatins frm. If the answer t any questin is YES, attach full details and apprpriate supprting dcuments with a signed and dated persnal explanatin. A. HAVE YOU EVER BEEN CONVICTED* OF ANY CRIME, FELONY OR MISDEAMEANOR, AND/OR DO YOU CURRENTLY HAVE ANY CRIMINAL CHARGES PENDING AND UNRESOLVED, IN ANY COURT? Yes (Attach dcuments and explanatin.) N B. FOR DISCIPLINARY REASONS, HAVE YOU EVER WITHDRAWN AN APPLICATION FOR A LICENSE, HAD AN APPLICATION FOR A LICENSE DENIED OR REFUSED OR AGREED NOT TO REAPPLY FOR A LICENSE IN ANY STATE, TERRITORY, POSSESSION OR COUNTRY? A LICENSE INCLUDES A REGISTRATION OR CERTIFICATION. Yes (Attach dcuments and explanatin.) N C. HAVE YOU EVER HAD A LICENSE SUSPENDED OR REVOKED OR OTHERWISE BEEN THE SUBJECT OF A DISCIPLINARY ACTION BY ANY LICENSING AUTHORITY IN ANY STATE, TERRITORY, POSSESSION OR COUNTRY? Yes (Attach dcuments and explanatin.) N * Cnvicted includes judgment, fund guilty by a judge r jury, pleaded guilty r nl cntendere, received prbatin withut verdict, dispsitin in lieu f trial r ARD. 11. AFFIDAVIT: READ, SIGN, AND DATE. In rder t cmply with federal statute, the State Bard f Nursing is bligated t infrm each applicant r licensee frm whm it requests a scial security number that disclsing such number is mandatry in rder fr this bard t cmply with the requirements f the federal Scial Security Act pertaining t child supprt enfrcement, as implemented in the Cmmnwealth f Pennsylvania at 23 PA C.S (a). In rder t enfrce dmestic supprt rders, at the request f the Cmmnwealth s Department f Public Welfare (DPW), the licensing bards must prvide t DPW infrmatin prescribed by DPW abut the licensee, including the scial security number. Additinally, disclsing the number is mandatry in rder fr this bard t cmply with the requirements f the federal Healthcare Integrity and Prtectin Data Bank. If this bard is required t make a reprt abut ne f its applicants r licensees t this data bank, it must reprt that individual s scial security number. I have read and understand all the infrmatin cntained herein, and will cmply with the requirements. I am f gd mral character, and, if requested, I shall furnish additinal evidence satisfactry t the Bard f Nursing. T the best f my knwledge and belief this applicatin cntains n misrepresentatins r falsificatins, missin r cncealments f material fact and the infrmatin given by me is true and cmplete. I understand that any false statement made is subject t the penalties f 18 Pa. C.S (relating t unswrn falsificatin t authrities) and may result in the suspensin, revcatin, r denial f my license r certificate. I understand that fees are nn-refundable and that in the event f any cmputer errr, hardware r sftware malfunctin, r if the examinatin is nt held fr any reasn, any claim I may have will be limited t the examinatin fee paid by me. I further understand that legal actin may be brught against me if I act in any manner which jepardizes the reliability, fairness, validity r security f the NCLEX examinatin. I verify that this frm is in the riginal frmat as supplied by the Department f State and has nt been altered r therwise mdified in any way. I am aware f the criminal penalties fr tampering with public recrds r infrmatin pursuant t 18 Pa. C.S Applicant s Full Legal Signature Date Enclse $ fr permanent licensure nly r $ if als requesting a Temprary Permit. This is a nn-refundable applicatin fee. This applicatin is valid fr ne (1) year frm the date the applicatin was signed. The prcess must be cmpleted within this time frame r yu will be required t submit a new applicatin and repay the applicatin fee. - Applicatin Page 2 f 3 revised TEX -

6 PENNSYLVANIA STATE BOARD OF NURSING P.O. BOX 2649 HARRISBURG, PA (717) FAX (717) VERIFICATION OF LICENSURE Part 1: T be cmpleted by applicant Cmplete the tp sectin f this frm and submit t yur riginal licensing authrity r, if applicable, cntact the Natinal Cuncil Verificatin website at Name: Last First Middle Maiden Name Current name n the riginal license: Mailing Address: Street (This name must be reprted n the Applicatin fr Licensure by Endrsement) City / State /Zip Cde Scial Security# Date f Birth / / MM DD YYYY I hereby authrize the release f any infrmatin regarding my licensure status t the Pennsylvania State Bard f Nursing. Applicant Signature Date Part 2: T be cmpleted by riginal licensing bard Please cmplete this sectin regarding the abve individual and return this frm t: Pennsylvania State Bard f Nursing P.O. Bx 2649 Harrisburg PA This is t certify that Applicant Name was issued license number n Basis fr licensure: Examinatin Other t practice as a Registered Nurse Practical Nurse. Has this license been disciplined in any manner r are disciplinary charges pending? N Yes* If yes, please attach details. Current licensure status: Active Inactive Lapsed Nursing Educatin Prgram Cmpleted: Lcatin(City, State/Prvince/Territry/Cuntry) Apprved by State/Prvince/Territry: Yes N Cmpletin Date: Type f Nursing Educatin Prgram: Baccalaureate Assciate Diplma Other Credential: Registered Nurse Practical Nurse Exam Infrmatin: Exam Type: NCLEX Results: Exam Date r Series: SBTPE Exam Date r Series: Other MED SUR OBS PED PSYCH Results: Exam Date r Series: SEAL Signature f Licensing Officer: Title: Name f Licensing Authrity: Lcatin: Date: - Applicatin Page 3 f 3 revised TEX -

7 STATE BOARD OF NURSING P.O. BOX 2649 HARRISBURG, PA PHONE: (717) FAX: (717) WAIVER OF SOCIAL SECURITY NUMBER VERIFICATION STATEMENT Name: Last First Middle Prfessin: This is t verify that I d nt have a scial security number fr the fllwing reasn(s): I verify that the statement made abve is true and crrect t the best f my knwledge, infrmatin and belief. I understand that any false statements made are subject t the penalties f 18 Pa. C.S. Sectin 4904 relating t unswrn falsificatin t authrities and may result in the suspensin r revcatin f my license. I will prceed t btain a Scial Security Number with all deliberate speed and prvide the Pennsylvania State Bard f Nursing with my Scial Security Number upn receipt. I understand that my license will nt be renewed unless I prvide prf f my Scial Security Number. Applicant Signature Date revised -