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)
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/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
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) 504-6430
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
_____________________ _______________________ ____________________________ ____________________ TypeoflicenseorcertificatebyEndorsement Number Stateorjurisdictionthatissuedthelicenseorcertificate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________ TypeoflicenseorcertificatebyEndorsement 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
________________________________________________ Name of school Program major
_____________________________ ________________ City State/Country
________________________________________________ Name of school Program major
_____________________________ ________________ City State/Country
High School or Primary School
________________________________________________ Name of school
_____________________________ ________________ City State/Country
________________________________________________ Name of school
_____________________________ ________________ City State/Country
_____ / ____
Month Year_____ / ____
Month Year
_____ / ____
Month Year_____ / ____
Month Year
Check appropriate type:
Graduatediploma
Graduateequivalency diploma
_____ / ____
Month Year_____ / ____
Month Year
_____ / ____
Month Year_____ / ____
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:___________________________________________________________________________________________
Address:____________________________________________________________________________________________ Streetaddress City State ZIPcode
Telephonenumber:__________________________________ (includeareacode)
Titleofyourposition:__________________________________________________ Hoursperweek:__________________
From____________________________________________ to________________________________________________ Month Year Month Year
Immediatesupervisor’snameandtitle:____________________________________________________________________
(c) Employer:___________________________________________________________________________________________
Address:____________________________________________________________________________________________ Streetaddress City State ZIPcode
Telephonenumber:__________________________________ (includeareacode)
Titleofyourposition:__________________________________________________ Hoursperweek:__________________
From____________________________________________ to________________________________________________ Month Year Month Year
Immediatesupervisor’snameandtitle:____________________________________________________________________
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:___________________________________________________________________________________________________
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
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
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) 504-6430
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
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Vermont (802)828-2396
Virginia (804)662-9909
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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
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