GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH HEALTH PROFESSIONAL LICENSING

GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH HEALTH PROFESSIONAL LICENSING APPLICATION INSTRUCTIONS AND FORMS FOR A LICENSE TO PRACTICE PRACTICAL NURSING, REGISTERED NURSING OR ADVANCED PRACTICE REGISTERED NURSING IN THE DISTRICT OF COLUMBIA Your interest in becoming licensed as a practical nurse, registered nurse, or advanced practice registered nurse in the District of Columbia is welcome. We look forward to providing expedient and professional service. However, the quality of our service is dependent on the completeness of your application. Please read the instructions carefully. All fees are earned when paid, and cannot be transferred or refunded except as specified in these instructions. This package contains the forms to apply for a nursing license in the District of Columbia. Follow the instructions provided below and complete all sections. If you require more space for work experience or need to provide explanations for screening questions, attach typed responses to the form. THE APPLICATION PROCESS Upon submission of the required application documents, the DC Board of Nursing will review your application. Upon final approval, you will be issued a license to practice in the District of Columbia or be authorized to sit for the NCLEX examination, if you are applying by examination or re-examination. If you submit an application that is incomplete or otherwise deficient, HPLA s processing staff will notify you of the deficiencies. If the Board has questions or concerns, you will also be notified. WHERE TO FILE Except for the examination scheduling form and examination fee (NCLEX-RN/PN exam and re-exam applicants only), documents should be sent to the following address: Department of Health Health Professional Licensing Administration DC Board of Nursing 717-14th St NW Suite 600 Washington, DC 20005 If you have any questions, call HPLA s Customer Service toll free line at 888-244-1689 between 8:00 a.m. and 5:00 p.m. EST Monday through Friday. Please read these instructions carefully to facilitate prompt processing of your application. Illegible applications and applications submitted without required signatures or with incorrect fees will be returned in their entirety, including fees. Please print or type all information except signatures. GENERAL REQUIREMENTS FOR ALL APPLICANTS All applicants for a nursing license in the District of Columbia shall meet the following requirements: 1. Applicant must be at least 18 years of age; and 2. Applicant must not have been convicted of a crime or moral turpitude which bears directly on the applicant s fitness to be licensed; and All applicants must submit the following in order to be considered for licensure: 3. A complete and signed application, including required supporting documents; and Page 1

4. Two passport-type photo of the applicant s face, measuring approximately 2 x 2 with the applicant s name printed on the back. Home snapshots are not acceptable. RN, LPN, AND APRN LETTERS OF SUPERVISED PRACTICE / TEMPORARY PERMIT TO PRACTICE When you apply, you may receive a Letter of Supervised Practice. This letter allows RN and LPN applicants to practice for 90 days in the District of Columbia under the supervision of a registered nurse, while your application is pending. This letter permits APRN applicants to practice your specialty under the supervision of an APRN certified by the Board while your application is pending. (TE: The supervising APRN must be certified in the same specialty as the APRN applicant.) You must submit: complete signed application, passport photo, a copy of your current license, the fee, and your supervised practice form. REQUIREMENTS: 1. In order to obtain a letter of supervised practice you must appear in person in the Department of Health office (address below) between the hours of 9:00 a.m. and 4:15 p.m. on Monday, through Friday with the following items: a. a picture ID; and b. a completed Supervised Practice Form (completed by your supervisor); and c. all other application documents 717-14th St NW Suite 600 Washington, DC 20005 2. A person who has been disciplined or against whom such action is pending (including a complaint pending resolution) in the District of Columbia or another jurisdiction, cannot work under supervised practice unless authorized by the Board to do so. COMPLETING THE LICENSE APPLICATION Section 1. Requested License Type / Fees a. There are three different methods for becoming licensed in the District of Columbia. These methods include: Examination (E) Re-examination (R) Endorsement (N) b. There are two license types from which to choose: LPN Licensed Practical Nurse RN Registered Nurse Successful completion of the NCLEX-RN or NCLEX-PN examination on the first attempt and meet other requirements. Successful completion of the NCLEX-RN or NCLEX-PN examination on the second or a later attempt and meet other requirements. Hold a license in good standing in another state or territory of the United States with standards which are comparable to DC s requirements. c. Four Advanced Practice Registered Nurse (APRN) specialty certifications are available: Nurse Anesthetist (anes) Nurse Midwife (mid) Nurse Practitioner (prac) Clinical Nurse Specialist (clin) TE: Advanced Practice Registered Nurse certification requires a registered nurse license. If you do not have a registered nurse license in the District, then you must apply for one at the same time you apply for certification as an Advanced Practice Registered Nurse. d. Mark the box next to the license type and origin (method) for which you are applying. e. Should you need to obtain additional copies of your license to comply with laws and regulations pertaining to displaying your license at each office where you conduct business, you may order up to five (5) duplicate licenses Page 2

(for $34 fee each, etc.). Mark the duplicate licenses box and indicate the number of duplicates needed on the line provided. Indicate the total amount due for duplicates on the line to the right. You may pay the application and license fee by a single check or money order. It is recommended that you pay by check, so that you have ready proof of payment. Checks or money orders should be made payable to DC Treasurer and submitted with your application packet. Do T send cash. Please print your name on your check, if it is not preprinted. The application portion of the fee is T refundable. The license fee portion of the payment is refundable in the event of final denial of a license or a request from an applicant to close the application request. In the latter event, you will have to file all documents again, should you subsequently decide to apply for licensure. *It will take approximately six (6) weeks after denial or withdrawal for you to receive your refund. For your information, the application and license fee portions of each application method are listed below: Line License Type Specialty Code Application Fee License Fee License Specialty Fee Total Due* 1. LPN EXAM $85 $102 $187 2. LPN RE-EXAM $85 ----- $85 3. LPN ENDOREMSENT $85 $145 $230 4. RN EXAM $85 $145 $187 5. RN RE-EXAM $85 ------ $85 6. RN-ENDORSEMENT $85 $111 $230 7. RN-adding APRN authority ANES $85** ----- $111 $119 to existing DC RN License 8. RN-adding APRN authority MID $85** ----- $111 $119 to existing DC RN License 9. RN-adding APRN authority PRAC $85** ----- $111 $119 to existing DC RN License 10. RN-adding APRN authority CLIN $85** ----- $111 $119 to existing DC RN License 11. 1 st Time APRN- RN License with one Authority Any One Specialty Above $85** $111 $111 $375 *The Total Enclosed amount is the fee that must be paid for your DC license to be processed. Your new license fee includes one new license print showing the new effective date and expiration date. A charge of $65.00 will be imposed for dishonored checks (Public Law 89-208). **TE: If you are applying for a RN license and an APRN certification on one application, then you need only pay one application fee. Example: One application is submitted for a RN license (via endorsement only) and a midwife certification. The total amount due = $287. Do not submit your NCLEX-RN/PN exam application and payment to HPLA. Send them to the address on the exam package. DC LPN licenses expire on June 30 of odd numbered years. RN licenses and APRN certifications expire June 30 of even numbered years. Your initial license will be valid for the balance of the current renewal cycle. You will be mailed a renewal notice (to your address of record) approximately three (3) months before the expiration of your license/certification. Upon completion of the renewal questionnaire and payment of the renewal fee, your license will be renewed for a two-year period. You should know that you are required by regulation to report all changes of your business or residence address to the Board within 30 days. HPLA will update the address change in your database record. Requests for address change should be made via a letter. Send the letter to HPLA at the address in the middle of page 1. Without an updated address, you may not receive your renewal notice. Page 3

Section 2. Applicant Name / Demographic Information Enter your name exactly as it should appear on the license. All applicants must be at least 18 years of age. Section 3. Supporting Documents Required The required supporting documents are listed in this section. Place an X in the box for each item you have included with your application package or requested to be sent under separate cover to DOH/HPLA on behalf of the Board of Nursing. If you are applying by Endorsement you must fill in section 3E and 3F with the names of your original state and most current state. Place an X in the box for each item that does not apply for the license type for which you are applying. Keep a photocopy of all supporting documents for your records. Section 4. Previous Names List any other names you have used in the past on the lines provided. If your name has changed at any point since you first attended a college or university, you must provide a copy of a legal name change document for EACH time that it has changed. Acceptable documents include a marriage certificate, divorce decree, court order or spouse s death certificate. Sections 5A. & B. Home Address / Business Address Include both your home and business addresses in the sections provided. Even if you have a PO box, a street address should also be provided. Please note your business address will appear on the DOH website. Section 5C. Preferred Mailing Address Place an X in the appropriate box to indicate your preferred mailing address. This will be the address to which all future licensing documents will be mailed. Section 6A. Nursing Schools Attended Mandatory field List all nursing schools that you have attended in reverse chronological order, beginning with the most recent at the top. RN applicants must have successfully completed an educational program and an approved school of registered nursing in the United States or its territories and, unless applying for examination, have received a passing score on: 1. The National Council Licensing Examination for Registered Nurses (NCLEX-RN) examination; or 2. Each part of the State Board Test Pool Examination for RNs (taken between January 1949 and February 1982); or 3. A state constructed examination taken prior to 1949; LPN applicants must be graduates of an approved school of practical nursing and have received a passing score on: 1. The National Council Licensing Examination for Practical Nurses (NCLEX-PN) examination; or 2. A score of 350 on each part of the State Board Testing Pool Examination for LPNs (taken before September 1982) The NCLEX-RN and NCLEX-PN examinations are computerized and will be offered to applicants after approval for examination by the DC Board of Nursing. Applicants must complete NCLEX Candidate Bulletins when applying for the examination in addition to the DC New License Application. You must register for the NCLEX-RN/PN examination by completing the registration forms and forwarding those forms with the fee specified in the NCLEX-RN/PN Candidate Bulletin to the Educational Testing Service. You should receive a copy of the NCLEX-RN/PN Candidate Bulletin with your exam application materials. Page 4

An official transcript (with seal) from an accredited school of nursing must be submitted with your application. The official transcript must reflect the date of graduation. This transcript may be sent directly from the school; but it is preferred that the transcript accompany the application in a sealed envelope. Applicants who completed an educational program in a foreign country (with the exception of Canada) may apply for a license, provided that the applicant meets all the requirements except for educational program approval and demonstrates to the satisfaction of the Board that the applicant has successfully completed the Commission on Graduates of Foreign Nursing Schools (CGFNS) examination. Applicants who graduated from nursing schools outside of the United States should successfully complete the CGFNS examination before applying to DOH/DC Board of Nursing or to NCLEX. To obtain additional information concerning the CGFNS examination, please write to: Commission on Graduates of Foreign Nursing Schools (CGFNS) 3624 Market Street Philadelphia, PA 19104 (215) 349-8767 www.cgfns.com Their cable address is CGFNS, Philadelphia, Pennsylvania USA. Section 6B. Professional Licenses In Other States / Jurisdictions If you are applying by endorsement, you must submit a copy of your original and most current license from another state or territory. Complete the top portion of the enclosed Endorsement of Registration Form. Send it to your state of original licensure. If you are not currently licensed in your original state, you must also send a second form to a current state. The form(s) must be returned directly to HPLA/DC Board of Nursing by the applicable state boards. If you are applying for Advanced Practice Registered Nurse certification, then you must complete the top of the enclosed APRN Specialty Form and forward it to the appropriate professional organization as indicated: Nurse Anesthetist: Nurse Mid-Wife: Nurse Practitioner: Clinical Nurse Specialist: American Association of Nurse Anesthetists American College of Midwives American Academy of Nurse Practitioners, American Nurses Credentialing Center, or other Nationally recognized accrediting body accepted by the Board American Nurses Credentialing Center or other Nationally recognized accrediting body accepted by the Board. Section 7. Screening Questions PLEASE TE: If you have been convicted of a crime or have had actions taken against your license, please provide official documentation which detail the outcome or current status of the case. If you answer yes to any of the questions (except question A), please provide a complete explanation on a separate sheet of paper. If more space is required to fully answer questions, attach additional sheets with typed responses. False or misleading statements will be cause for disciplinary action and could be cause for criminal prosecution pursuant to DC Code 22-2514. Section 8. Licensee Affidavit By signing the application you are attesting under penalty of perjury that all information and attached documents are true to the best of your knowledge. Page 5

SUMMARY OF APPLICATION REQUIREMENTS The following chart shows the application submission requirements for all application methods. The law governing nursing licensure in the District of Columbia is D. C. Law 6-99, the Health Occupations Revision Act of 1985. The regulations governing nursing licensure are included in DC Municipal Regulations Title 17, Chapters 40, 41, 54, 55, 57, 58, and 59. Any conflict between these instructions and the law and regulations is inadvertent. The law and the regulations take precedence in the event of any inadvertent conflict. Please contact the Department of Health/Board of Nursing if you have any questions regarding the interpretation of these laws as they pertain to your particular situation. SUMMARY OF LICENSURE REQUIREMENTS FOR D.C. NURSING LICENSES License Type Application Method Signed Application Nursing School Transcript Two 2 x 2 Photos Endorsement Form - Original State Endorsement Form - Current State* CGFNS Certificate** ARN Certificate Check or Money Order*** NCLEX Exam Application**** LPN Examination X X X O O X O $187 X Reexamination X O X O O O O $85 X Endorsement X O X X X O O $230 O RN Examination X X X O O X O $187 X Reexamination X O X O O O O $85 X Endorsement X O X X X O O $230 O RN Adding Specialty only X O X O O O X $119 O X = Required O = Not required * An endorsement form from a current state is only required if you are not currently licensed in your original state. TE: It is the applicant s responsibility to send the endorsement forms to the appropriate states and direct their return to DOH/HPLA at the address given in these instructions. Applicants should check with their states of licensure to find out the fee for completing endorsement forms. ** Only required for graduates of nursing schools outside of the United States. *** Check or money order MUST be made payable to DC Treasurer. **** This form together with the appropriate examination fee should be sent with the indicated fee to the Educational Testing Service at the address shown in the NCLEX-RN or NCLEX-PN Candidate Bulletin. ***** Applicants for certification for advanced practice registered nursing specialties must be licensed in the District of Columbia as a RN or apply for licensure as a RN. (See the Fee Matrix in the Completing the License Application section of these instructions for fees applicable to simultaneous application of RN and APRN licensure/certification.) Page 6

GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH HEALTH PROFESSIONAL LICENSING ADMINISTRATION NEW LICENSE APPLICATION BOARD OF NURSING Please read instructions before completing this form. If you have any questions, call HPLA Customer Service at 1-877-244-1689, Monday through Friday, 8AM to 5PM EST. A charge of $65.00 will be imposed for dishonored checks (Public Law 89-208) SECTION 1. REQUESTED LICENSE TYPE/FEES (includes non-refundable application fee see instructions) Endorsement Make check or money order payable to LPN RN Licensed by Endorsement $230.00 DC Treasurer. APRN Authorities APRN First time applicant Advance Practice and Registered Nurse by Endorsement (select one): $375.00 Nurse Anesthetist Nurse Practitioner Nurse Midwife Clinical Nurse Specialist Adding APRN authority to existing DC RN License Number: DC RN # Advanced Practice Registered Nurse (select one): $230.00 Nurse Anesthetist Nurse Practitioner Nurse Midwife Clinical Nurse Specialist Each additional APRN authority $119.00 Advanced Practice Registered Nurse (select one): Nurse Anesthetist Nurse Practitioner Nurse Midwife Clinical Nurse Specialist Examination LPN RN Licensed by Examination $187.00 LPN RN by Re-Examination $85.00 MAIL TO: Department of Health Health Professional Licensing Administration Board of Nursing 717-14 th St NW, Suite 600 Washington, DC 20005 Walk-in Service 717 14 th St NW Suite 600 Washington, DC 20005 HPLA ONLY Check $ Check # Staff $.00 Duplicates Duplicate Licenses (limit 5) X $34.00 Total Enclosed $.00 SECTION 2. APPLICANT NAME/DEMOGRAPHIC INFORMATION Enter your name exactly as it should appear on the license. If your name has changed at any point since you first attended college or university, please complete Section 4 on page 2. You must also provide a copy of a legal name change document for EACH time that it has changed. Acceptable documents for individuals are marriage certificates, divorce decrees, or court orders. FIRST NAME MI LAST NAME SUFFIX (Jr., Sr., etc.) SOCIAL SECURITY NUMBER If applicant does not provide a social security number, a sworn affidavit is required. DATE OF BIRTH (mm/dd/yyyy) PLACE OF BIRTH Provide City and State for US birthplace or Country for foreign place of birth. Male Female GENDER Please check the correct box. SECTION 3. A. B. C. SUPPORTING DOCUMENTS REQUIRED Please indicate the supporting documents you have included with this package or requested to be sent to the Board of Nursing. Keep Two recent and identical passport-type photos of the applicant s face (approx. 2 X2 ) with applicant s name and SSN printed on the back. The photos must be original photos and cannot be computer-generated copies or paper copies. If a graduate of a nursing school other than in the United States and Canada, an official transcript of your Council for Graduates of Foreign Nursing Schools (CGFNS) certificate. * No copies accepted. Please indicate the country where your nursing school is located : USA Canada Other Official transcript (with seal) from the applicant s school of nursing, with cover letter from school. May be sent directly from the school, but is preferred that it accompany the application in a sealed envelope. EXAM APPLICANTS ONLY D. Copy of most recently obtained license from other state or territory. HPLA ONLY Page 1

GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH HEALTH PROFESSIONAL LICENSING ADMINISTRATION NEW LICENSE APPLICATION E. Verification from your original state Board of licensure or NURSYS verification website. Please indicate state: F. Verification from your most current (if different from original) state of licensure. Please indicate state: G. Verification from Advanced Practice Registered Nurse Specialty Certifying Board Form. H. Copies of legal documents supporting all name changes. SECTION 4. PREVIOUS NAMES If your name has changed at any point since you first attended college or university, you must provide a copy of a legal name change document for EACH time that it has changed. Acceptable documents for individuals are marriage certificates, divorce decrees, or court orders. Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate FIRST NAME MI LAST NAME SUFFIX Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate (Jr., Sr., etc.) FIRST NAME MI LAST NAME SUFFIX Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate (Jr., Sr., etc.) FIRST NAME MI LAST NAME SUFFIX Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate (Jr., Sr., etc.) FIRST NAME MI LAST NAME SUFFIX (Jr., Sr., etc.) SECTION 5A. HOME ADDRESS Even if you have a PO Box, a street address should also be provided, if applicable. APARTMENT SUITE FLOOR PO BOX NUMBER HOME STREET ADDRESS 1 (If applicable, use this line for additional building information. Otherwise, use this line to indicate STREET NUMBER and STREET NAME) HOME STREET ADDRESS 2 (If additional space is needed, use this line to indicate STREET NUMBER and STREET NAME) CITY STATE ZIP CODE + 4 HOME PHONE NUMBER HOME FAX NUMBER E-MAIL ADDRESS SECTION 5B. BUSINESS ADDRESS Please note: This information will be made available to the public. COMPANY NAME APARTMENT SUITE FLOOR PO BOX NUMBER BUSINESS STREET ADDRESS 1 (If applicable, use this line for additional building information. Otherwise use this line to indicate STREET NUMBER and STREET NAME) BUSINESS STREET ADDRESS 2 (If additional space is needed, use this line to indicate STREET NUMBER and STREET NAME) CITY STATE ZIP CODE + 4 BUSINESS PHONE NUMBER BUSINESS FAX NUMBER E-MAIL ADDRESS Page 2

SECTION 5C. GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH HEALTH PROFESSIONAL LICENSING ADMINISTRATION PREFERRED MAILING ADDRESS NEW LICENSE APPLICATION Indicate your preferred mailing address by placing an X in the appropriate box. This will be the address to which all future licensing documents will be mailed. The address that will appear on your license will be your business address. HOME BUSINESS SECTION 6A. NURSING SCHOOLS ATTENDED List all nursing schools that you have attended, in reverse chronological order, beginning with the most recent at the top. EXAM APPLICANTS ONLY: Transcripts must be provided for all schools listed below. MANDATORY FIELD School Name, City, State, Country Number of Hours Completed Date of Graduation Type of Degree/Certificate SECTION 6B. PROFESSIONAL LICENSES IN OTHER STATES/JURISDICTIONS List all states and jurisdictions in which you have ever held a license. Provide letters of verification from original and current jurisdictions (if different). MANDATORY FIELD Jurisdiction Date License Was First Obtained License Number SECTION 7. QUESTIONS Applicants MUST answer all of the following questions. Please answer all of the following questions by placing an X in the appropriate boxes. If you answer Yes to questions B through J below, you must provide full information and complete details on a separate sheet of paper, including copies of relevant court documents, and attach to this application. A.Clean Hands Before Receiving a License or Permit Act of 1996 Certification Form Requirement. Please read the information below carefully before responding to this yes or no question, as any false information provided requires that the Department of Health proceed immediately to revoke your License or Permit for which you are now applying, and fine you one thousand dollars ($1,000.00), pursuant to D.C. Official Code 47-2864 (2001). IF YOU ANSWER TO THIS QUESTION, PLEASE SUBMIT PROOF OF THE ARRANGEMENTS YOU HAVE MADE TO PAY THE OUTSTANDING DEBT. IF YOU DO T HAVE AN APPROVED PAYMENT SCHEDULE TO PAY THE AMOUNT YOU OWE OR IF APPEAL IS PENDING, THE LAW REQUIRES THAT YOUR RENEWAL APPLICATION BE DENIED. As of this date, do you owe more than one hundred dollars ($100.00) to the District of Columbia Government as a result of any of the following: Yes No 1. Fines, penalties, or interest assessed pursuant to D.C. Official Code Title 8, Chapter 8 (Litter Control Administrative Act of 1985); 2. Fines or interest assessed pursuant to D.C. Official Code Title 8, Chapter 9 (Illegal Dumping Enforcement Act of 1994); 3. Fines, penalties, or interest assessed pursuant to D.C. Official Code Title 2, Chapter 18 (Civil Infractions Act of 1985); 4. Past due taxes; 5. Past due District of Columbia Water and Sewer Authority service fees; or 6. Fines or penalties assessed pursuant to D.C. Official Code Title 50, Chapter 23 (Traffic Adjudication)? HPLA ONLY The information presented above is in compliance with the requirement to submit with your application for licensure or permit under the Clean Hands Before Receiving a License or Permit Act of 1996, effective May 11, 1996 (D.C. Law 11-118, D.C. Code 47-2861 et seq.). B. Has the use of drugs and/or alcohol resulted in an impairment of your ability to practice your profession? C. Have you ever been convicted or arrested for a crime (other than minor traffic violations) not previously reported to the Board? Page 3

GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH HEALTH PROFESSIONAL LICENSING ADMINISTRATION NEW LICENSE APPLICATION D. Are you now or have you ever been licensed in DC or any other state/jurisdiction? (If "Yes," be sure to complete Section 6B of this form.) E. Have you ever been party to a malpractice action or had a malpractice action brought against you? F. Have you ever voluntarily surrendered a license after formal charges have been filed against you or while under investigation? G. Have you ever been terminated from or resigned from a clinical or professional training program? H. Do you have a physical or medical condition that currently impairs your ability to practice your profession? I. (1) Have you withdrawn an application (in D.C. or any other state/jurisdiction) to practice your profession? (2) Has any authority or peer review board taken adverse action against your license or privileges? (3) Are you currently under investigation or were you investigated by any authority or peer review board for any violation of state, federal, or local law? (4) Has any authority or peer review board informed you of any pending charge(s) or investigation not previously re ported to this Board? J. Have you ever been terminated or asked to resign from employment since obtaining your (professional) license? SECTION 8. LICENSEE AFFIDAVIT I hereby attest that the information given in this application, including all writings and exhibits attached hereto, is true and complete to the best of my knowledge. I understand that the making of a false statement on this application, including all writings and exhibits attached hereto, is punishable by criminal penalties. HPLA ONLY LICENSEE SIGNATURE NAME (Please Print) DATE To report waste, fraud, or abuse by any DC Government office or official, call the DC Inspector General at 1-800-521-1639. Page 4

Department of Health Health Professional Licensing Administration District of Columbia Board of Nursing 717-14 th Street, NW; Suite 600 Washington, DC 20005 NURSING LICENSURE VERIFICATION FORM TO BE COMPLETED BY APPLICANT Applicant s Name SS# Address Telephone E-mail Name original license was issued under License Number State/Territory ------------------------------------------------------------------------------------------------------------ TO BE COMPLETED BY LICENSING AUTHORITY Please verify this registration and give the following information: License Issued by: Examination Endorsement Date Issued: Expiration Date: Is applicant currently licensed? Yes No *Has licensee ever been disciplined? (Placed on Probation, Yes No License Denied, Revoked, Suspended, or Surrendered, etc.) Remarks *If licensee is currently under disciplinary sanctions please forward all orders to the District of Columbia Board of Nursing along with this form. On behalf of the State/Territory of I certify that the above statements are correct. Verified by: Board Seal Date: Revised: 04/05