Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE. LICENSE BY ENDORSEMENT Applicant must submit the following:

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1 Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT Nursing (802) Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE If you have graduated from a nursing education program outside of the United States and have passed the NCLEX-RN examination this is the wrong application. Go to the International Nurse page on the website and complete the International RN NCLEX Pass Endorsement Application. LICENSE BY ENDORSEMENT Applicant must submit the following: 1. Complete Vermont Application 2. Application Fee of $ (n-refundable Processing Fee). Checks/Money orders are payable to Vermont Secretary of State. Credit/Debit cards are not accepted. 3. Verification of Licensure Provide verification of your original nursing license as well as the nursing license from your most recent state of nursing employment. If those states are members of NURSYS, go to and obtain license verification(s) for Vermont. (te: The Quick Confirm Report does not suffice.) If those states do not participate in electronic verification through NURSYS, use the additional pages 8 & 9 to request verification from those boards. 4. If requesting a temporary license, a clear photocopy of your current out-of-state nursing license (showing expiration date) is required. If you have already verified this license to Vermont via NURSYS, then a copy with the application is not needed. 5. Copy of Drivers License, government issued ID or passport 6. 2x2 Photo (Passport sized photo of head and shoulders taken within the last 6 months other than your driver s license or passport). NOTE: Any change of address or other contact information, by an applicant or licensee, must be forwarded to this office no later than thirty (30) days after change occurs. Send completed form to: Vermont Board of Nursing Montpelier, VT RN Endorsement Application

2 Vermont Secretary of State Montpelier VT Licensing Board Specialist (802) Vermont Board of Nursing Registered Nurse Endorsement Application 2x2 Recent Photo- Paste Here Passport sized photo of head and shoulders taken within the last 6 months. Application Fee: $ (nonrefundable) Office Use Only (Use Ink or Typewritten only) First Name (Legal name; no nicknames) Middle Last Name Previous Name(s) (Maiden) Social Security Number: / / ** (Providing your social security number (SSN) is mandatory, and requested under the authority granted by 42 U.S.C. 405(c)(2)(C). It will be used by the Departments of Taxes, Child Support, and the Department of Labor in the administration of Vermont law, to identify individuals affected by such laws. Your SSN is not disclosed as part of a public records request); te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14). P.O. Box Mailing Address: Street/Apt # City/State/Zip Country Box Street/Apt # 911 Address: (if different than mailing) Suite/Department/Floor City/State/Zip Phone: ( ) - Cell Phone: ( ) - Work: Date of Birth Gender: (Circle One) Place of Birth (city, state, country) Female Male RN Endorsement Application

3 Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license. RN Endorsement Application

4 Section C: Vermont Mandatory Credential and Fitness Questions Circle or for each of these questions. If the answer is, follow the instructions provided. Have you committed acts of abuse, neglect, or misappropriation of patient property? If, provide a detailed written explanation and attach all related documents. Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Have you ever surrendered a license, certificate or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Have you EVER been convicted of a crime other than a minor traffic violation? (Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. ) If, you must provide a detailed written explanation and attach the official court documents (i.e., affidavit of probable cause, the information and/or the docket report.) Do you have any criminal charges pending against you in any jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. te: Vermont law requires that you report to the a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Are you currently participating in a supervised program or professional assistance program which monitors you in order to assure that you are not engaging in the use of alcohol or controlled substances? If, please provide the contract/stipulation under which you are practicing. RN Endorsement Application

5 Section D: LICENSE INFORMATION State of original licensure: Original license number Date issued: All other states in which you hold or have held a nursing license: (Please attach additional sheets if necessary) State Date Licensed Expiration/Inactive Date License Number Section E: PRACTICE REQUIREMENTS 1. I graduated from my entry level RN education program within the last five years. Complete the information below regarding the program that lead to your initial RN licensure: Name of Nursing School/College/University City State Date of Graduation MM/DD/YYYY Degree Earned 2. I have practiced as a registered nurse as defined in 26 V.S.A., Rules Part 9, 9.1 (b) (c) for at least 50 days (400 hours) within the last 2 years or 120 days (960 hours) within the last five years: Please note that if you DO NOT meet the work history requirement and have graduated within the last five years you must also file the Verification of Education - RN (Domestic) form. This form must be completed by your school of nursing, and sent directly to our office along with an official copy of your transcripts. (You may also bring these documents from the school in a sealed envelope) You will not be issued a temporary license until this form has been received and reviewed by the Nursing Board. RN Endorsement Application

6 3. Provide the following information for all RN employment within the last 5 years (paid, volunteer, or private duty work); attach additional sheets if necessary: All items must be completely filled in. Position # 1 (most recent) Your Job Title Paid or Volunteer? Full Time Part Time Date of Employment Name of Agency/Institution P.O. Box From (MM/DD/YYYY) / / To (MM/DD/YYYY) / / Mailing Address Street/Apt # City/State/Zip/Country Agency/Institution Phone # Supervisor s Name and Title Position # 2 Your Job Title Paid or Volunteer? Full Time Part Time Date of Employment Name of Agency/Institution Mailing Address From (MM/DD/YYYY) / / P.O. Box Street/Apt # City/State/Zip/Country To (MM/DD/YYYY) / / Agency/Institution Phone # Supervisor s Name and Title RN Endorsement Application

7 4. If you practiced as a registered nurse in a private duty capacity or as a volunteer, attach: Private Duty: 1. An Official letter from the Attending Provider on their letter head, stating that RN care was required. The letter must clearly list the Providers name, title, contact telephone number and have their signature. 2. A letter from your Employer or Client, verifying your role and duties as a Private Duty Nurse. They must verify the number of days, hours and dates worked. The letter must clearly list the Employer/Clients name, contact telephone number, address, mailing address and have their signature. Volunteer: 1. An Official letter from your Employer sent directly to the Vermont Board of Nursing office from the Director of Nursing or Director of Human Resources. A copy of your Job Description as a Volunteer Nurse, and a letter listing the number of days, hours and dates worked. The letter must clearly list the name of the Director of Nursing or Director of Human Resources, their telephone number, address, mailing address and have their signature. 5. I have successfully completed a Board approved RN Re-entry/Refresher program (Nursing Administrative Rules - Part 8, 8.7 (a) (b) (c) (d).) If you have completed a re-entry program please attach a photocopy of your certificate of completion as well as the re-entry program curriculum, including total theory and clinical hours. Name of RN Re-entry/Refresher program: Date RN Re-entry/Refresher program completed: Section F: Verification of Licensure (MM/DD/YYYY) Provide verification of your original nursing license as well as the nursing license from your most recent state of nursing employment. If those states are members of NURSYS, go to and obtain license verification(s) for Vermont. (te: The Quick Confirm Report does not suffice.) If those states do not participate in electronic verification through NURSYS, use the additional pages 7 & 8 to request verification from those boards. A permanent license will be issued if your application is complete, approved, and includes verification of your nursing license(s) from your exam state and most recent working state. I am requesting a temporary license to practice as a RN until the necessary verification(s) can be obtain from my state board(s) of nursing: THE 90 DAY TEMPORARY LICENSE CAN NOT BE EXTENDED. Section G: Required Enclosures The following MUST be submitted with your application for licensure. A clear photocopy of your current out-of-state nursing license (showing expiration date) A clear photocopy of your current driver s license, government issued ID or passport. All required documents must be received by this office within 6 months of receipt of this application. If application remains incomplete after 6 months it will be destroyed. If you are interested in reapplying, a new application and fee must be submitted. RN Endorsement Application

8 Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant Date RN Endorsement Application

9 Vermont Secretary of State Montpelier VT Board of Nursing (802) VERIFICATION OF INITIAL LICENSURE Complete the applicant section of this form and forward it to the Board of Nursing in which you obtained your initial license. Please Print. Most Boards of Nursing charge a fee to complete this form. Applicant: Licensed as: Date of Birth: License #: First Name MI Last Name & Title (Jr., Sr., II, III, etc.) Former/Maiden P.O. Box Mailing Address: Street/Apt # City/State/Zip Country I hereby authorize the License Agency to furnish to the Vermont the information requested below. Signature Date: Information Below To Be Completed by the Licensing Agency: License # Date Issued: Date Expired: Licensed By: Examination/Education Endorsement/Reciprocity License Status If licensed/certified by endorsement please indicate state or country endorsed from: Active Inactive/Lapsed Name of Exam taken: Degree Awarded: Graduation Date: Education Name of Nursing Education program completed: City, State Country Has this license ever been encumbered in anyway (revoked, suspended, limited, surrendered, restricted, placed on probation)? If yes, attach a copy of the decision YES NO Signature of person completing form: Date: State Completing this form: City/State: Telephone: STATE LICENSING AUTHORITY: Mail to Vermont Secretary of State (OFFICIAL SEAL) Board of Nursing Montpelier, VT VERIFICATION OF INITITAL LICENSURE RN Endorsement Application

10 Vermont Secretary of State Montpelier VT Board of Nursing (802) VERIFICATION OF LICENSURE OF MOST RECENT NURSING EMPLOYMENT Complete the applicant section of this form. Have the state of your most recent employment complete this page. Please Print. Most Boards of Nursing charge a fee to complete this form. Applicant: Licensed as: Date of Birth: License #: First Name MI Last Name & Title (Jr., Sr., II, III, etc.) Former/Maiden P.O. Box Mailing Address: Street/Apt # City/State/Zip Country I hereby authorize the License Agency to furnish to the Vermont the information requested below. Signature Date: Information Below To Be Completed by the Licensing Agency: License # Date Issued: Date Expired: Licensed By: Examination/Education Endorsement/Reciprocity License Status If licensed/certified by endorsement please indicate state or country endorsed from: Active Inactive/Lapsed Has this license ever been encumbered in anyway (revoked, suspended, limited, surrendered, restricted, placed on probation)? If yes, attach a copy of the decision YES NO Signature of person completing form: Date: State Completing this form: City/State: Telephone: STATE LICENSING AUTHORITY: Mail to Vermont Secretary of State Board of Nursing Montpelier, VT (OFFICIAL SEAL) RN Endorsement Application

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