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⭐REINSTATEMENT APPLICATION PRACTICAL NURSE APPLICANT INSTRUCTIONS
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1 Colorado Division of Registrations Office of Licensing Nursing 1560 Broadway, Suite 1350 Denver, CO Phone: (303) / FAX: (303) REINSTATEMENT APPLICATION PRACTICAL NURSE APPLICANT INSTRUCTIONS Nurse Licensure Compact. The Nurse Licensure Compact is effective in Colorado on October 1, 2007, allowing nurses licensed in Colorado to practice in other compact states. A nurse may hold only one compact license and it must be issued by his/her state of primary residence. If you declare your primary state of residence to be a compact state other than Colorado, you should not apply for licensure in Colorado. If you declare a non-compact state as your state of primary residence, and you meet all other requirements for licensure in Colorado, you will receive a single-state license valid for practice only in Colorado. Compact states are: Arizona, Arkansas, Delaware, Idaho, Iowa, Kentucky, Maine, Maryland, Mississippi, Nebraska, New Hampshire, New Mexico, North Carolina, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, and Wisconsin. Additional information about the Nurse Licensure Compact is available on our website at Mandatory Practice Act. Colorado has a mandatory practice act, which means that you may not practice as a Practical Nurse in this state without a Colorado or other compact state license. Submission of this application does not guarantee licensure. Therefore, do not make life or career decisions based on the probability that you may receive a license. Plan ahead for the time it will take to receive and review all required documents and complete our evaluation. Basic Requirements. Requirements for licensure are outlined in the Colorado Revised Statutes, specifically ; the Board s rules; and the Board s policies. These documents are available online at About the Application. This application is to be completed by you and returned to the Office of Licensing. All questions on the application are mandatory, and all supporting documents must be submitted with the application. The application forms must be completed in original ink or typed. Keep a copy of the completed application and supporting documents for your records. Failure to complete the application thoroughly or to submit all supporting documents may delay processing. Application Good for One Year. Your application will be kept on file for one year from the date of receipt. Your file and all supporting documentation will be purged if you do not submit required documents and complete your application process in one year. You will need to submit a new application packet and fee after that time. Social Security Number is Required. By Colorado statute, you must provide your social security number. If you do not have a United States social security number, you must complete an SSN affidavit. The affidavit is available on our website at or you may call (303) to request that one be mailed to you. Disclosure of Addresses. Consistent with Colorado law, all addresses and phone numbers on record with the division are public record and must be provided to the public when requested. It is your responsibility to keep your address and contact information up-to-date in our database. All letters, renewal notices, and licenses are mailed to the last known address of record. If your address is not current, it is possible you will not receive important documents. You can change your address online by using Registrations Online Services at License Expiration Grace Period for Reinstatement Applicants. Practical Nurse license expiration dates are June 30 of even-numbered years. All new applicants who are issued a license within 120 days of the upcoming renewal expiration date will be issued a license with the subsequent expiration date. For example, licenses issued between March 1, 2008 and June 30, 2008 will reflect a license expiration date of June 30, Licenses issued prior to March 1, 2008 will reflect an expiration date of June 30, 2008 and must renew in the upcoming renewal period. Checking Your Application Status. Visit Registrations Online Services at to track your application from the date we log it in our database to the date your license is printed. Please allow us enough time to receive the application through the mail and enter your application into our database before you check the website. We recommend waiting at least 10 business days from date of mailing before checking the status of your application. IV Authority. If you are an LPN with IV authority, you must submit a separate application after your license is reinstated. Applications are available online at Retired/Volunteer Nurse Status. You may apply for reinstatement as a Retired/Volunteer Nurse if you are at least 65 years of age. You may not accept compensation for nursing tasks performed. Applicant: Keep this page for your records. 8/20072 APPLICANT CHECKLIST To apply for reinstatement of your Practical Nurse license, you must: Complete the attached Reinstatement Application. Return the completed application and all supporting documentation to the Office of Licensing. Enclose the non-refundable application-processing fee. See page 1 of the application form for current fees. Fees may be paid by a check or money order drawn in U.S. dollars and made payable to State of Colorado. All fees are non-refundable and subject to change every July 1. Complete and return the attached Affidavit of Eligibility Form. Effective January 1, 2007, and pursuant to CRS , all applicants for licensure are required to complete and sign an Affidavit of Eligibility, and may also be required to provide a secure and verifiable document. If your license has been expired for more than two years, you must demonstrate competency to practice. Refer to Part 5 for detailed instructions. Return your completed application packet and all supporting documentation to: Division of Registrations Office of Licensing Nursing 1560 Broadway, Suite 1350 Denver, CO Applicant: Keep this page for your records. 8/20073 NURSE LICENSURE COMPACT INFORMATION PLEASE READ CAREFULLY Colorado will implement the Nurse Licensure Compact on October 1, Implementation may affect your Colorado RN or LPN license. The Nurse Licensure Compact (NLC) is a mutual recognition model of licensure that allows a Registered Nurse (RN) or Licensed Practical Nurse (LPN) to hold one license in his or her primary state of residence and to practice in other compact states. Significant licensure changes that will take place on October 1, 2007 are: 1. Nurses who live in other compact states will obtain and renew their license in their primary state of residence. If you declare another compact state as your primary state of residence, your Colorado license will expire and you will need to obtain an active license in your state of residency. 2. Nurses who live in a non-compact state and apply for licensure in Colorado will be issued a single state license valid for practice only in Colorado. 3. Nurses whose license is restricted will receive a single state license valid for practice only in Colorado. 4. Nurses who move from one compact state to another compact state have 30 days to obtain licensure in their new compact state of primary residence. 5. Advanced Practice (RNs), Prescriptive Authority, and IV Authority (LPNs) must be applied for in each state in which the nurse intends to practice. All licensees will receive notification of Compact requirements a minimum of 90 days prior to implementation. The notification will contain instructions regarding declaring a primary state of residence and will be mailed to the address of record. It is imperative that your contact information is up-to-date. All letters and renewal notices are mailed to the last known address of record. Address changes may be made online by using Registrations Online Services at: Additional information about the Nurse Licensure Compact can be found on our website at4 DEPARTMENT OF REGULATORY AGENCIES Division of Registrations STATE OF COLORADO Department of Regulatory Agencies D. Rico Munn 1560 Broadway, Suite 1350 Executive Director Denver, Colorado Phone (303) Division of Registrations Fax (303) Rosemary McCool TTY: Dial 711 for Relay Colorado Director Dear Applicant: Bill Ritter, Jr. Governor Thank you for your interest in becoming a licensed professional within the Division of Registrations. Before you submit your application, I want to make you aware of a few facts regarding criminal conduct, convictions, and disciplinary actions in other states. The mission of the Division of Registrations is public protection through effective licensure and enforcement. One way the Division safeguards the public is by issuing licenses to fully qualified, competent, and ethical applicants. During the licensing process and depending on the specific application the Division will ask whether you have ever been disciplined in any state, arrested, charged, convicted, or pled guilty to a crime. An arrest, subsequent criminal conviction, or disciplinary action is not an automatic disqualification from licensure. Instead, the appropriate board or program will look at the facts surrounding the criminal conduct and disciplinary action to determine whether you are fit for licensure. You should know that licensure is a privilege, not a right. One thing you must do to obtain the privilege is to be completely honest on your licensure application. Be sure to list all relevant complaints, disciplinary actions, arrests, charges, or convictions in response to the licensure questions. Failure to fully disclose could constitute grounds alone for denial of your application or revocation of your license. More important, avoid some of the common excuses we have heard from people who failed to disclose, such as: My attorney told me I didn t have to disclose the criminal conduct or disciplinary actions. I didn t think the prior conduct had anything to do with the profession. I didn t think the disciplinary action, arrest, charges, or conviction was still on my record. I didn t think it was subject to disclosure because I received a deferred sentence/judgment. Remember, there is no excuse not to disclose disciplinary actions and criminal conduct. Even after licensure, you are still required to notify your professional licensing board or program about subsequent convictions and disciplinary actions in other states. The Division conducts annual audits of its licensing database against several criminal and national disciplinary databases. This allows the Division to verify the truthfulness of your application and track subsequent criminal and disciplinary conduct after initial licensure. Keep in mind, you will not necessarily be revoked or denied a license if you have been disciplined, arrested, charged or convicted, but you will most likely be denied or revoked if you fail to disclose it. Sincerely, Rosemary McCool, Director Division of Registrations5 Colorado Department of Regulatory Agencies Division of Registrations 1560 Broadway, Suite 1350 Denver, CO AFFIDAVIT OF ELIGIBILITY Pursuant to H.B. 06S-1009, C.R.S , ALL applicants for original licensure or licensees renewing a current Colorado license after January 1, 2007 are required to complete and sign this Affidavit of Eligibility. Section A: LAWFUL PRESENCE in the United States. I, (please print your full name), swear or affirm under penalty of perjury under the laws of the State of Colorado that (check 1, 2 or 3 below): 1. I am a US citizen. 2. I am not a US citizen but am lawfully present in the US as evidenced by one of the following a. I am a qualified alien as defined in 8 U.S.C. sec b. I am a nonimmigrant under the Immigration and Nationality Act, Federal Public Law as amended. c. I am an alien who is paroled into the US under 8 U.S.C. sec (d) (5). 3. I am not physically present in the US under 8 U.S.C. sec 1621 (c) (2) (c) or employed in the US pursuant to 8 U.S.C (c) (2) (a) (check either a or b below): a. I am a US citizen, not physically present or employed in the United States. b. I am a Foreign National, not physically present or employed in the United States. If you selected either 3.a. or 3.b., you do not need to complete Section B. Skip to Section C. Section B: Secure and Verifiable Document. This section must be completed if you checked number 1 or 2 in Section A. 1. Please check one of the following acceptable secure and verifiable documents. Complete documentation must be provided upon request only. Any Colorado Driver License, Colorado Driver Permit or Colorado Identification Card, expired less than one year. (Temporary paper license with invalid Colorado Driver License, Colorado Driver Permit, or Colorado Identification Card, expired less than one year is considered acceptable.) Out-of-state issued photo Driver's License or photo identification card, photo driver s permit expired less than one year. Valid foreign passport bearing an unexpired Processed for I-551 stamp or with an attached unexpired Temporary I-551 visa. Valid I-551 Resident Alien or Permanent Resident card. Valid foreign passport accompanied by an I-94 indicating a specific future until date. Valid I-94 issued by Canadian government with L1 or R1 status and a valid Canadian driver s license or valid Canadian identification card. Valid Temporary Resident Card. Valid I-94 with refugee/asylum stamp. (document list continued on page 2) Affidavit of Eligibility - Page 1 of 2 Updated March 16, 20076 Valid 1688B or 1766 Employment Authorization Card. Valid US Military ID (active duty, dependent, retired, reserve and National Guard). Tribal Identification Card with intact photo (US or Canadian). Certificate of Naturalization with intact photo. Certificate of (US) Citizenship with intact photo. Passport issued by the U.S. Government with one of the following documents: Social Security card; marriage, divorce or separation certificate or decree; or a Colorado or Federal tax return. Colorado Department of Corrections Inmate Identification Card with a Social Security card issued by the United States Government. 2. Enter the state or the federal agency name where this secure and verifiable document was issued. 3. What is the secure and verifiable document number? (If issued by a state agency, include both the state and agency name.) 4. What is the expiration date of your secure and verifiable document? / / (month/day/year) (If you hold a document without an expiration date, such as a military ID or naturalization certificate, write N/A.) Section C: Attestation. I understand that this sworn statement is required by law because I have applied for or hold a professional or commercial license regulated by 8 U.S.C. sec I understand that state law requires me to provide proof that I am lawfully present in the United States when asked as well as submission of a secure and verifiable document. I may also be required to provide proof of lawful presence. I understand that in accordance with sections and (2)(a)(I), C.R.S., false statements made herein are punishable by law. I state under penalty of perjury in the second degree, as defined in , C.R.S. that the above statements are true and correct. I am the person identified above and the information contained herein is true and correct to the best of my knowledge. I understand that under Colorado law, providing false information is grounds for denial, suspension or revocation of a license, certificate, registration or permit. I understand that the above information must be disclosed to the Department of Regulatory Agencies upon request and is subject to verification. Signature Please print your name as shown on your secure and verifiable document. Professional License Type: License Number (if already licensed): Affidavit of Eligibility - Page 2 of 2 Updated March 16, 20077 Colorado Division of Registrations Office of Licensing Nursing 1560 Broadway, Suite 1350 Denver, CO Reinstatement Application PRACTICAL NURSE Active Status Fee: $121 Retired/Volunteer Nurse Status Fee: $20 The content of this application must not be changed. If the content is changed, the applicant may be referred to the Colorado State Attorney General s Office for violation of Colorado law. Please select a license status: I wish to reinstate with full ACTIVE status. Fee: $121 I wish to reinstate with RETIRED/VOLUNTEER NURSE status. Fee: $20 (To be eligible for Retired/Volunteer Nurse status, you must be 65 years of age or older and you may not accept compensation for nursing tasks performed as a volunteer.) Colorado Practical Nurse License No.: License Expired: PART 1. Name: Last: First: Middle: Previous Name(s): You must include a copy of legal name change document. Social Security Number: * of Birth (mm/dd/yy): Gender: Male Female Place of Birth (city and state, or foreign country): Mailing Address: This is a Home Business PO Box, Street: City, State, Zip: Daytime Telephone Number: ( ) Address: PART 2. A. Since the date your Colorado nursing license expired, have you been practicing as a Practical Nurse in the State of Colorado? B. List each jurisdiction, other than Colorado, in which you are or have ever held any health care license. (If necessary, attach an additional sheet using the same format.) Type of license State/Country License # Year license issued Disciplinary action against license? Is this license current/active? *Social Security Number Disclosure: Section (1) of the Colorado Revised Statutes requires that every application by an individual for a license issued pursuant to the authority set forth in title 12, C.R.S., by the Department of Regulatory Agencies, shall require the applicant's social security number. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support under and , C.R.S.; locating an individual who is under an obligation to pay child support as required by (3)(a)(I)(A), C.R.S.; and reporting disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR 61.1 et seq. Failure to provide your social security number for these mandatory purposes will result in the denial of your licensure application. Disclosure of your social security number is voluntary for disclosure to other state regulatory agencies, testing and examination vendors, law enforcement agencies, and other private federations and associations involved in professional regulation for identification purposes only. Your social security number will not be released for any other purpose not provided for by law. Page 1 of 4 8/20078 APPLICANT NAME: PART 3. If you respond to any of the following questions, you must provide the following for each response: An explanation, signed and dated by you, of your behavior or practice that led to the occurrence, including: o (s) of event/offense o Description of event/offense o Location/court o Current status/outcome You may be required to provide the following: Copies of legal documents relating to the event/offense. Copies of legal documents indicating your compliance with any requirements imposed upon you. 1. Has any nursing or other health care license held by you been denied, revoked, suspended, reprimanded, fined, surrendered, restricted, limited, or placed on probation in any state other than Colorado or in any territory of the United States? 2. Are you under investigation or is a disciplinary action pending against your nursing license or other health care license in any state or territory of the United States? 3. Have you received notification from the Department of Health and Human Services, Office of the Inspector General, that you have been excluded from participation in Medicare, Medicaid or any federal health care programs? 4. Have you ever been convicted, entered a plea of guilty, nolo contendere, or no contest for any felony, misdemeanor or petty offense? The fact that a conviction has been pardoned, expunged, dismissed, deferred, or that your civil rights have been restored does not mean that you answer this question ; you should answer. 5. Have you ever been convicted, pled no contest/nolo contendere, or had a court accept a plea to a criminal motor vehicle offense of DUI/DWI/DWAI/OWI or any traffic offense involving drugs or alcohol? The fact that a conviction has been pardoned, expunged, dismissed, deferred, or that your civil rights have been restored does not mean that you answer this question ; you should answer. 6. Has any final judgment, settlement or arbitration award for malpractice been paid by you or on your behalf? 7. Do you have a physical or mental disability which renders you unable to perform nursing services or duties with reasonable skill and safety and which may endanger the health and safety of persons under your care? 8. Are you now or have you in the past five (5) years been addicted to any controlled substance, a regular user of any controlled substance without a prescription, or habitually intemperate in the use of intoxicating liquor? 9. Have you been terminated or permitted to resign in lieu of termination from a nursing or other health care position because of your use of alcohol or use of any controlled substance, habit-forming drug, prescription medication, or drugs having similar effects? 10. Have you been arrested for an alcohol or drug-related offense other than stated in question No. 5? Page 2 of 4 8/20079 APPLICANT NAME: PART 4. Declaration of Primary State of Residence. Primary State of Residence is defined as the state of a person s declared fixed permanent and principal home for legal purposes; domicile. You may be asked to provide proof of residency. I declare that the state of such constitutes my permanent and principal home for legal purposes. is my primary state of residence and that Declaration of State(s) of Current Practice. Upon licensure in Colorado, I intend to practice in the state(s) of: Attach additional sheets if necessary. I will practice exclusively at a government / military facility and am requesting a Colorado single-state license. PART 5. Has your Colorado license been expired more than two (2) years?. Your application is complete. Please sign, date, and submit your application to the Office of Licensing.. You must demonstrate competency by one of the following methods (please select either Option A or Option B below and follow the corresponding instructions). This section and all attached forms referenced in this section applies only to individuals whose license has been expired for more than two (2) years. Competency to practice may be established by one of the following methods: (Select either Option A or Option B) A. Demonstration of the active practice of nursing in another state, federal facility, or U.S. territory during the two (2) years preceding the filing of this reinstatement application. If you select this option, you are attesting that you have worked during the two (2) years preceding the submission of this application and you must submit the following with your application: Verification of Current Licensure. Contact the state in which you hold an active license to determine their fee and which of the verification forms you need to submit. For participating states, you must apply for NURSYS Verification through the NURSYS website (a current list of participating states can be found at OR For non-participating states, you must complete and submit a Request for Verification of Nursing License form (attached). Every effort will be made to expedite this application. This process may take anywhere from two weeks to several months, depending on your circumstances and how quickly you submit the supporting documentation required. You can help speed this process by supplying all the required supporting documents and responding quickly to requests for information made by staff. -- OR -- (continued on next page) Page 3 of 4 8/200710 APPLICANT NAME: B. Successfully completing refresher courses as defined in Nursing Board Policy If you select this option, you must complete all three of the following steps: 1. Register for a Board-approved nursing education program / refresher course. 2. Within the guidelines of your chosen program / course, locate a qualified clinical agency (acute, subacute, skilled) to obtain the required, unpaid supervised clinical experience. Submit a completed Non-Traditional Refresher/Remedial Program Instructor/Preceptor Agreement (attached) with your application and fee to the Office of Licensing, 1560 Broadway, Suite 1350, Denver, CO Upon review and approval of the application and Preceptor Agreement, your license will be reinstated in a Restricted Status, valid only for the purpose of completing the clinical experience. 3. Upon completion of steps 1 and 2 above, provide evidence of having completed all requirements as follows: a. Obtain an official transcript or certificate in its official sealed envelope indicating completion of the Board-approved nursing education program or theory section of a refresher course; b. Obtain a completed Non-Traditional Refresher/Remedial Program Skills Checklist from your Preceptor (attached) in an official sealed envelope. c. Submit both documents in their unopened, sealed envelopes to the Office of Licensing. Upon review and approval of both documents, the restriction will be removed from your license and a new license will be issued in an Active Status. ATTESTATION In accordance with sections and (2)(a)(I), Colorado Revised Statutes, false statements made herein are punishable by law. I state under penalty of perjury in the second degree, as defined in C.R.S. that the information contained in this application is true and correct to the best of my knowledge. I understand that under the Colorado Nurse Practice Act, providing false information is grounds for denial, suspension, or revocation of a nursing license. Signature of Applicant Page 4 of 4 8/200711 Colorado Division of Registrations Office of Licensing Nursing 1560 Broadway, Suite 1350 Denver, CO Phone: (303) / FAX: (303) PN REQUEST FOR VERIFICATION OF NURSING LICENSE You are responsible for ensuring your state of licensure sends verification to the Colorado Office of Licensing. You are also responsible for ensuring its receipt by the Colorado Office of Licensing. PART 1: To be completed by the APPLICANT and forwarded to state of licensure with fee determined by that state. Last Name First Middle Previous Name(s) Mailing Address (PO Box, Street, City, State, & ZIP) Social Security Number of Birth Licensed under the name of Year of License Original license number I hereby authorize all Boards of Nursing to release my license data to the Colorado Board of Nursing. Applicant Signature PART 2: To be completed by the LICENSING BOARD of the state of licensure and sent to the Colorado Office of Licensing. Licensed by Exam: Score State Board Exam PN NCLEX Series/Form Licensed by Endorsement: State: License/Registration Number Issued License Expiration Has any disciplinary action EVER been taken against this license? If, please send certified copies of all disciplinary actions. Is license now in good standing? If, please attach documentation. (Board Seal) Signature Title Board of Nursing / State12 PN N-TRADITIONAL REFRESHER / REMEDIAL PROGRAM INSTRUCTOR / PRECEPTOR AGREEMENT (All information requested in this form must be provided) Student name (print legibly) Colorado License Number This Agreement, by and between the Student, Instructor/Preceptor, Faculty*, and Facility, is entered into for the purpose of providing clinical experience to Student pursuant to Colorado State Board of Nursing ( BON ) Policy 10-03, which is incorporated herein by reference. See For good and valuable consideration, the parties, whose information is fully set forth below, agree as follows: Instructor/Preceptor agrees to provide (circle one): (A) clinical supervision in a traditional format with one instructor directly overseeing a small group of students OR (B) direct supervision of student on a 1:1 basis. Instructor/Preceptor agrees to evaluate Student s performance pursuant to the BON Non-Traditional Refresher/Remedial Program Checklist and to provide student with the required evaluation upon Student s completion of the clinical portion of the refresher/remedial course. In addition, Instructor/Preceptor will provide official transcripts and the Skills Checklist in a sealed envelope to student for submission to BON; Faculty* agrees that its non-traditional program will provide theoretical course work to Student as required by BON Policy 10-03; Facility agrees that the clinical instruction required herein may be provided at its facility. Instructor/Preceptor: Instructor/Preceptor signature Printed Name: Title/Position: Phone number: License No(s): RN PN Status of License(s): State(s) licensed: Year(s) Issued: Exp. date(s): Educational degrees: Yrs. clinical experience: Schools attended & years graduated: Faculty: Faculty member signature Printed name of school: Address of school: Printed name of faculty member: Title: Phone number: address: Fax number: Facility: Facility representative signature Printed name of facility: Address of facility: Facility provides (circle all that apply): acute care subacute care nursing facility PN only Printed name of facility representative: Title: address: Phone number: Fax number: Student: Student signature * Faculty: Individuals meeting the requirements of the rules, designated by the governing body as having ongoing responsibility for curriculum development, planning, teaching, guiding, monitoring, and evaluating student learning in the classroom and practice setting.13 PN N-TRADITIONAL REFRESHER / REMEDIAL PROGRAM Skills Checklist Student: Social Security Number: Program: Faculty/Preceptor: Clinical Supervision Start : End : > Please mark each competency as Pass or Fail < Clinical Competencies Pass Fail PN Provider Role Performs services under the supervision of a registered nurse, physician, dentist or podiatrist. Performs and accurately collects basic health assessment data on patients contributing to the comprehensive patient assessment. Identifies common needs and problems, recognizes normal from abnormal findings and reports changes in findings to the appropriate health care professional. Contributes to the nursing plan of care. Provides basic care to those patients with predictable outcomes. Administers treatments, including medications as prescribed within the plan of care. Includes the medical plan of care and the nursing plan of care with: Has accurate knowledge of the treatment procedure, and expected outcome. Skilled in safely administering the treatment. Administers the right treatment to the right patient, at the right time. Documents accurately and in a timely manner. Communicates to appropriate authority in a timely manner if patient refuses treatment, error is made, or an unpredicted event occurs. Uses technology, information and facility resources appropriately and effectively. Communicates in an accurate, clear and respectful manner with patients, families, supervisors and other Health Care Providers. Develops and maintains appropriate relationships with patients, families, colleagues, and other health care professionals. Participates in the evaluation of patient outcomes and implementing necessary change. Assists in the formation of a teaching plan based on the needs of the patient. Supports and reinforces teaching as prescribed in the plan of care. Reports changes in individual / family / group condition in a timely manner and to the appropriate supervisor. Preceptor Initials Skills Checklist Page 1 of 214 Clinical Competencies Pass Fail PN Professional Role Is current in knowledge of illness care and treatment trends. Promotes patient safety. Is a safe practitioner that practices within the PN scope of practice. Maintains patient confidentiality. Protects self and patients through safe practices such as universal precautions, lifting guidelines, and self-care practices. When directed coordinates, organizes and prioritizes care provided for the patient. Assigns care appropriately. Monitors care provided by assignees. Offers feedback to assignees on care provided. Uses effective communication and conflict management skills. Promotes teamwork. PN Preceptor Initials I affirm that the clinical experience described on this form was conducted and completed in accordance with Colorado State Board of Nursing Policy I further affirm that the clinical experience was completed under my supervision. I declare under penalty of perjury in the second degree that the statements made herein are true and complete to the best of my knowledge. Printed Name and Address of Preceptor: Colorado License Number: Preceptor Signature: Signed Student Signature: Signed Instructor/Preceptor will provide the Skills Checklist in a sealed envelope to student for submission to BON. Skills Checklist Page 2 of 2 View more
Colorado Division of Professions and Occupations Office of Licensing Nursing 1560 Broadway, Suite 1350 Denver, CO 80202 Phone: (303) 894-7800 / Fax: (303) 894-7693 www.dora.colorado.gov/professions APPLICATION More information LICENSURE BY EXAMINATION APPLICATION
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Dear Applicant for Nursing Licensure in New Mexico, Thank you for applying for licensure as a nurse in New Mexico. The information in this packet is designed to provide you with the necessary information More information OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST APPLICATION INSTRUCTIONS AND INFORMATION General Statement: More information APPLICATION FOR ORIGINAL REGISTRATION MASSAGE THERAPIST APPLICANT INSTRUCTIONS
Colorado Division of Registrations Office of Licensing Massage Therapy 1560 Broadway, Suite 1350 Denver, CO 80202 Phone: (303) 894-7800 FAX: (303) 894-7693 www.dora.state.co.us/registrations APPLICATION More information APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.
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State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Veterinarian APPLICANT INFORMATION Full Legal Name: First Middle Last All Previous Legal Names: More information This is a Legal Document. By completing and signing this, you certify under
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PUBLIC RECORD: This application is a public record for purposes of the Maine Freedom of Access Law (1 MRSA 401 et seq). Public records must be made available to any person upon request. This application More information ENDORSEMENT (RECIPROCITY) APPLICATION FOR LPNs and RNs
ENDORSEMENT (RECIPROCITY) APPLICATION FOR LPNs and RNs Instructions This application is used to endorse a nursing license that you have already obtained within the United States, but have never held a More information VOCATIONAL REHABILITATION COUNSELOR
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE VOCATIONAL REHABILITATION COUNSELOR APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah Division More information This is a Legal Document. By completing and signing this, you certify under
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State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Temporary Physical Therapist Temporary Physical Therapist Assistant APPLICANT INFORMATION Full Legal More information PUBLIC RECORD: This application is a public record for purposes of the Maine Freedom of Access Law (1 MRSA 401 et seq). Public records must be made
PUBLIC RECORD: This application is a public record for purposes of the Maine Freedom of Access Law (1 MRSA 401 et seq). Public records must be made available to any person upon request. This application More information RADIOLOGIC TECHNOLOGIST or RADIOLOGY PRACTICAL TECHNICIAN
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE RADIOLOGIC TECHNOLOGIST or RADIOLOGY PRACTICAL TECHNICIAN APPLICATION INSTRUCTIONS AND INFORMATION General Statement: More information CERTIFIED MEDICAL LANGUAGE INTERPRETER
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State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Retired Volunteer Health Care Practitioner APPLICANT More information Dear Applicant, General Reminders: notarized Section A: You must submit a copy of at least one of the following documents Section B:
Dear Applicant, For those of you who are applying for licensure by examination, congratulations on completing your educational program and welcome to the profession of nursing. If you have any questions More information REQUIREMENTS FOR LICENSURE:
Email: st-medicine@pa.gov INITIAL APPLICATION FOR A NURSE-MIDWIFE LICENSE 1. This license class does not include prescriptive authority. If you wish to hold a certificate for prescriptive authority, you More information STATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR COLON HYDROTHERAPY UPGRADE TO MASSAGE THERAPIST LICENSE WITH INSTRUCTIONS
STATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR COLON HYDROTHERAPY UPGRADE TO MASSAGE THERAPIST LICENSE WITH INSTRUCTIONS Board of Massage Therapy 4052 Bald Cypress Way, Bin # C-06 Tallahassee, More information Dear Applicant: Sincerely, Kelli Dalrymple, Coordinator Medical and Specialized Health. Licensure Unit
Please Reply To: Licensure Unit P.O. Box 94986, Lincoln, NE 68509-4986 Phone (402) 471-2118 FAX (402) 471-3577 Dear Applicant: Thank you for your interest in becoming licensed to practice your profession More information Licensure by Examination Information For Graduates from Nursing programs within the United States
17938 SW Upper Boones Ferry Road Portland, Oregon 97224-7012 Licensure by Examination Information For Graduates from Nursing programs within the United States Non-United States Graduate: If you studied More information INSTRUCTIONS FOR APPLICANTS WHO HOLD NBRC CERTIFICATION
Email: st-medicine@pa.gov st-osteopahtic@pa.gov Medicine 717-783-1400/717-787-2381 Osteopathic 717-783-4858 APPLICATION FOR LICENSURE AS A RESPIRATORY THERAPIST This application can be used for licensure More information APPLICATION FOR LICENSURE LICENSED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR INTERN
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE LICENSED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR INTERN More information Application for New Louisiana Pharmacy Technician Candidate Registration
Louisiana Board of Pharmacy 3388 Brentwood Drive Baton Rouge, Louisiana 70809-1700 Telephone 225.925.6496 ~ Facsimile 225.925.6499 www.pharmacy.la.gov ~ E-mail: info@pharmacy.la.gov Application for New More information State of Utah Department of Commerce Division of Occupational and Professional Licensing
State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Clinical Mental Health Counselor APPLICANT INFORMATION More information ACCOUNTING PRACTITIONER LICENSING REQUIREMENTS
ACCOUNTING PRACTITIONER LICENSING REQUIREMENTS 1. No prior history of dishonest or felonious acts: 2. Be a resident of this State or have a place of business in this State, or as an employee, be regularly More information Instructions For Clinical Nurse Specialist (CNS) Applicants
DIVISION OF MEDICAL QUALITY ASSURANCE BOARD OF PHARMACY 4052 BALD CYPRESS WAY, BIN #C-04 TALLAHASSEE, FLORIDA 32399-3254 (850) 245-4292 PHARMACY TECHNICIAN REGISTRATION APPLICATION AND INSTRUCTIONS October More information A $100.00 application fee in the form of a money order made payable to LSBN must accompany this form
OFFICE USE ONLY: APPROVED BY (initial) DATE PERMIT ISSUED RN LICENSE NUMBER DATE RN LICENSE ISSUED ATTACH PHOTO With tape only - Attach a 2 x 2 inch passport type, fade-proof photo taken in the last six More information Vermont Board of Nursing INSTRUCTION TO APPLICANTS
Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing Foreign_nurse@sec.state.vt.us www.vtprofessionals.org INSTRUCTION TO APPLICANTS The following applies to applications More information 2. Be of good moral character. Have 2 recommendations completed on page 3.
STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1389 FAX 717-787-7769 Email st-socialwork@state.pa.us Website www.dos.pa.gov/social More information TECHNICIAN-IN-TRAING IS NOT PERMITTED TO PRACTICE IN MONTANA IN ANY MANNER WITHOUT AN ACTIVE MONTANA REGISTRATION
Page 1 of 8 MONTANA BOARD OF PHARMACY (301 S PARK, 4 TH FLOOR, HELENA, MT 59601 - Delivery) P. O. Box 200513 Helena, Montana 59620-0513 PHONE (406) 841-2300 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov More information APPLICATION FOR WYOMING REGISTERED NURSE LICENSURE by ENDORSEMENT, RELICENSURE or REACTIVATION All licenses expire December 31 of every EVEN year
INSTRUCTIONS AND GENERAL INFORMATION: APPLICATION FOR WYOMING REGISTERED NURSE LICENSURE by ENDORSEMENT, RELICENSURE or REACTIVATION All licenses expire December 31 of every EVEN year Thank you for applying More information Iowa Dental Assistant Registration & Dental Radiography Qualification Application
Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 717-783-1400/717-787-2381 APPLICATION FOR More information Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: web@dsps.wi.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov BOARD OF NURSING More information APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR DENTAL HYGIENE
Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510 APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR More information APPLICATION FOR A LICENSE TO PRACTICE SOCIAL WORK (THIS APPLICATION MUST BE SUBMITTED FOR PRE-APPROVAL TO TAKE THE ASWB MASTER S EXAMINATION)
STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P O BOX 2649 HARRISBURG, PA 17105 717-783-1389 st-socialwork@pa.gov Fax 717-787-7769 www.dos.pa.gov/social APPLICATION More information WYOMING LICENSED PRACTICAL NURSE LICENSURE BY ENDORSEMENT, RELICENSURE
APPLICATION FOR WYOMING LICENSED PRACTICAL NURSE LICENSURE BY ENDORSEMENT, RELICENSURE or REACTIVATION All licenses expire December 31 of every EVEN year INSTRUCTIONS AND GENERAL INFORMATION: Thank you More information APPLICATION FOR WYOMING REGISTERED NURSE LICENSURE with APRN RECOGNITION All licenses expire December 31 of every EVEN year
APPLICATION FOR WYOMING REGISTERED NURSE LICENSURE with APRN RECOGNITION All licenses expire December 31 of every EVEN year INSTRUCTIONS AND GENERAL INFORMATION: Thank you for applying to the Wyoming State More information APPLICATION FOR PHARMACIST EXAMINATION
Applicant s Name: 9901/001 Application $ 50.00 9901/001 Licensure fee $ 165.00 9901/006 Regulatory fee $ 10.00 9901/001 Application $300.00 9901/001 Score Transfer $165.00 9901/006 Regulatory fee $10.00 More information Board of Speech-Language Pathology and Audiology
Board of Speech-Language Pathology and Audiology Application for Speech-Language Pathology or Audiology Provisional Licensure With Instructions Attached Board of Speech-Language Pathology and Audiology More information This is a Legal Document. By completing and signing this, you certify under penalty of perjury
APPLICATION FOR WYOMING REGISTERED NURSE (RN) or LICENSED PRACTICAL NURSE (LPN) By EXAMINATION *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this, More information PENNSYLVANIA STATE BOARD OF DENTISTRY P.O. BOX 2649 HARRISBURG, PA 17105-2649
PENNSYLVANIA STATE BOARD OF DENTISTRY APPLICATION FOR CERTIFICATION AS A PUBLIC HEALTH DENTAL HYGIENE PRACTITIONER Introduction: Instructions and Application Form Please read the following instructions More information ALL APPLICANTS MUST COMPLETE THE FOLLOWING:
APPLICATION FOR ATHLETIC TRAINER LICENSE (This application may also be used for a temporary license) 1. An applicant for licensure shall meet one of the following requirements: a. Be a graduate of an approved More information INSTRUCTIONS FOR APPLICANTS WHO HOLD NBRC CERTIFICATION
Email: st-medicine@pa.gov st-osteopahtic@pa.gov Medicine 717-783-1400/717-787-2381 Osteopathic 717-783-4858 APPLICATION FOR LICENSURE AS A RESPIRATORY THERAPIST This application can be used for licensure More information Texas Board of Nursing 333 Guadalupe, Ste 3-460, Austin, TX 78701 Phone: 512-305-7400
For Office Use Only Date: Amount: Texas Board of Nursing 333 Guadalupe, Ste 3-460, Austin, TX 78701 Phone: 512-305-7400 PETITION FOR DECLARATORY ORDER Audit #: FBI HX: YES NO Complete this application More information Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 Ship To: 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: dsps@wisconsin.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov BOARD More information STATE OF FLORIDA BOARD OF ACUPUNCTURE APPLICATION FOR LICENSURE WITH INSTRUCTIONS
STATE OF FLORIDA BOARD OF ACUPUNCTURE APPLICATION FOR LICENSURE WITH INSTRUCTIONS Board of Acupuncture 4052 Bald Cypress Way, Bin # C-06 Tallahassee, FL 32399-3256 (850) 488-0595 September 2012 Edition More information CHECK THE CIRCUMSTANCE UNDER WHICH YOU ARE SEEKING A TEMPORARY LICENSE: REQUIRED DOCUMENTS
Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1400/717-787-2381 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 APPLICATION FOR More information Licensure by Endorsement Instructions
2829 University Avenue SE #200 Licensure by Endorsement Instructions If you have been licensed in a state or territory of the United States by examination, you must obtain a Minnesota license through the More information Certified Registered Nurse Anesthetist General Instructions for Licensure Application
4305 S. LOUISE AVENUE SUITE 201 SIOUX FALLS, SD 57106-3115 (605) 362-2760 Fax: 362-2768 doh.sd.gov/boards/nursing General Instructions for Licensure Application Please follow instructions carefully to More information DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions
DEPARTMENT OF HEALTH BOARD OF CLINICAL SOCIAL WORK, MARRIAGE AND FAMILY THERAPY AND MENTAL HEALTH COUNSELING APPLICATION FOR LIMITED LICENSURE and Instructions APPLICATION FOR LIMITED LICENSURE INSTRUCTIONS More information REQUIREMENTS FOR CERTIFICATION:
Email: st-medicine@pa.gov INITIAL APPLICATION FOR NURSE-MIDWIFE PRESCRIPTIVE AUTHORITY * A separate prescriptive authority collaborative agreement must be submitted for each physician, physician group More information APPLICATION FOR PHARMACY TECHNICIAN REGISTRATION Information for Individuals who desire to register as a Pharmacy Technician
NAME 9906/001 Application $75.00 9906/006 Regulatory $10.00 STATE OF TENNESSEE DEPARTMENT OF HEALTH DIVISION OF HEALTH LICENSURE AND REGULATION www.tennessee.gov/health APPLICATION FOR PHARMACY TECHNICIAN More information Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing
MED THE STATE of ALASKA Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing State Medical Board PO Box 110806, Juneau, AK 99811-0806 More information INSTRUCTIONS FOR HEARING AID DISPENSING APPLICATION
BOARDS AND COMMISSIONS DIVISION New Mexico Speech-Language Pathology, Audiology and Hearing Aid Dispensing Practices Board PO Box 25101 Santa Fe, New Mexico 87505 (505) 476-4640 Fax (505) 476-4620 www.rld.state.nm.us More information Licensure by Endorsement Instructions
Licensure by Endorsement Instructions If you have been licensed in a state or territory of the United States by examination, you must obtain a Minnesota license through the process of licensure by endorsement. More information TEXAS BOARD OF NURSING 333 Guadalupe #3-460, Austin, Texas 78701 (512) 305-7400
TEXAS BOARD OF NURSING 333 Guadalupe #3-460, Austin, Texas 78701 (512) 305-7400 APPLICATION FOR SIX MONTH TEMPORARY PERMIT TO COMPLETE REFRESHER COURSE, EXTENSIVE ORIENTATION, OR NURSING PROGRAM OF STUDY More information APPLICANTS MUST COMPLETE THE FOLLOWING:
Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1400/717-787-2381 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 APPLICATION FOR More information INSTRUCTIONS for REINSTATEMENT or RETURN to ACTIVE STATUS of RN or LPN LICENSE
Oklahoma Board of Nursing 2915 N. Classen Boulevard, Suite 524 Oklahoma City, OK 73106 (405) 962-1800 www.ok.gov/nursing INSTRUCTIONS for REINSTATEMENT or RETURN to ACTIVE STATUS of RN or LPN LICENSE Application More information INSTRUCTION TO APPLICANTS FOR LICENSURE AS A OCCUPATIONAL THERAPIST OR OCCUPATIONAL THERAPY ASSISTANT
INSTRUCTION TO APPLICANTS FOR LICENSURE AS A OCCUPATIONAL THERAPIST OR OCCUPATIONAL THERAPY ASSISTANT A. TEMPORARY LICENSE (90 DAYS)- Applicant must submit the following: Temporary licenses are valid for More information MONTANA BOARD OF PUBLIC ACCOUNTANTS
MONTANA BOARD OF PUBLIC ACCOUNTANTS 301 South Park 4 th Floor PO Box 200513 Helena Mt 59620 0513 Phone: 406 841 2203 E mail: dlibsdpac@mt.gov Website: www.publicaccountant.mt.gov APPLICATION FOR ORIGINAL More information Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510
Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510 APPLICATION FOR RECOGNITION TO ADMINISTER LOCAL ANESTHESIA More information GEORGIA BOARD OF PHARMACY 2 Peachtree Street, N.W. 36 th Floor Atlanta, Georgia 30303
GEORGIA BOARD OF PHARMACY 2 Peachtree Street, N.W. 36 th Floor Atlanta, Georgia 30303 PHARMACY TECHNICIAN INFORMATION SHEET AND CHECKLIST In accordance with O.C.G.A. 26-4-28, the Georgia Board of Pharmacy More information BOARD OF CHIROPRACTIC MEDICINE GENERAL INFORMATION/INSTRUCTIONS REGISTERED CHIROPRACTIC ASSISTANT
BOARD OF CHIROPRACTIC MEDICINE GENERAL INFORMATION/INSTRUCTIONS REGISTERED CHIROPRACTIC ASSISTANT HOW TO APPLY FOR FLORIDA LICENSURE *** PLEASE TYPE OR PRINT IN BLACK INK - PLEASE READ CAREFULLY *** 1. More information REVISED 07-15 STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649
STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649 Email st-socialwork@pa.gov www.dos.pa.gov/social APPLICATION FOR A LICENSE More information APPLICATION FOR NATIONAL EXAMINATION IN MARITAL & FAMILY THERAPY
Minnesota Board of Marriage and Family Therapy 2829 University Avenue SE, Suite 400 Minneapolis, MN 55414-3222 Telephone: (612) 617-2220 Fax: (612) 617-2221 Email: mft.board@state.mn.us Website: www.bmft.state.mn.us More information STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR APPROVAL TO TAKE EXAMINATIONS ELECTRICIAN
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR APPROVAL TO TAKE EXAMINATIONS ELECTRICIAN APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah Division More information CERTIFIED PUBLIC ACCOUNTANT
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE CERTIFIED PUBLIC ACCOUNTANT APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah Division of More information REGISTERED NURSE or LICENSED PRACTICAL NURSE
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE REGISTERED NURSE or LICENSED PRACTICAL NURSE APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The More information Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A LICENSED NURSING ASSISTANT
Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing (802) 828-3089 www.vtprofessionals.org Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A LICENSED More information Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: web@dsps.wi.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov PSYCHOLOGY EXAMINING More information NOTE: All mailings will be sent to the address you indicate below; if you change your address, you must advise this office.
ATTACHMENT G 7/2013 STATE OF NEBRASKA Department of Health and Human Services Division of Public Health - Licensure Unit P.O. Box 94986 - Lincoln, Nebraska 68509-4986 Telephone #: 402-471-4918 Rita.watson@nebraska.gov More information STATE OF FLORIDA BOARD OF MASSAGE THERAPY MASSAGE ESTABLISHMENT CHANGE OF LOCATION/ NAME APPLICATION WITH INSTRUCTIONS
STATE OF FLORIDA BOARD OF MASSAGE THERAPY MASSAGE ESTABLISHMENT CHANGE OF LOCATION/ NAME APPLICATION WITH INSTRUCTIONS Board of Massage Therapy 4052 Bald Cypress Way, #C-06 Tallahassee, FL 32399-3256 (850) More information APPLICATION FOR A LICENSE BY EXAMINATION TO PRACTICE MARRIAGE AND FAMILY THERAPY
QUALIFICATIONS STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649 Email st-socialwork@state.pa.us Website www.dos.pa.gov/social More information PHYSICAL THERAPIST AND PHYSICAL THERAPY ASSISTANT LICENSE APPLICATION PACKET
THE STATE of ALASKA Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing Board of Physical Therapy and Occupational Therapy State Office More information North Carolina Veterinary Medical Board VETERINARY TECHNICIAN STATE EXAM APPLICATION
North Carolina Veterinary Medical Board VETERINARY TECHNICIAN STATE EXAM APPLICATION 1611 Jones Franklin Road, Suite 106, Raleigh NC 27606 Phone: (919) 854-5601 EXAM DATE APPLICATION DEADLINE January 6, More information STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE PHYSICAL THERAPIST
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE PHYSICAL THERAPIST APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah Division of Occupational More information SOCIAL SERVICE WORKER (SSW), CERTIFED SOCIAL WORKER INTERN (CSWI), CERTIFIED SOCIAL WORKER (CSW), or LICENSED CLINICAL SOCIAL WORKER (LCSW)
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE SOCIAL SERVICE WORKER (SSW), CERTIFED SOCIAL WORKER INTERN (CSWI), CERTIFIED SOCIAL WORKER (CSW), or LICENSED More information PLEASE READ BEFORE COMPLETING APPLICATION
PLEASE READ BEFORE COMPLETING APPLICATION Information for Licensure: SOCIAL WORKER (LSW) Each item on the enclosed application must be completed. Allow 30 days for processing of the application. Failure More information GEORGIA BOARD OF DENTISTRY 2 Peachtree Street, N.W. 6 th Floor Atlanta, Georgia 30303 www.gbd.georgia.gov
APPLICATION FOR VOLUNTEERS IN DENTISTRY/DENTAL HYGIENE INITIAL LICENSURE GEORGIA BOARD OF DENTISTRY 2 Peachtree Street, N.W. 6 th Floor Atlanta, Georgia 30303 www.gbd.georgia.gov Please read the instructions More information FEES ARE NON REFUNDABLE
STATE OF TENNESSEE DEPARTMENT OF HEALTH DIVISION OF HEALTH LICENSURE AND REGULATION OFFICE OF HEALTH RELATED BOARDS 665 MAINSTREAM DRIVE NASHVILLE, TN 37243 TENNESSEE BOARD OF NURSING 615-532-5166 or 1-800-778-4123 More information INSTRUCTIONS for RE-WRITING the LICENSURE EXAMINATION
Oklahoma Board of Nursing 2915 North Classen Boulevard, Suite 524 Oklahoma City, Oklahoma 73106 (405) 962-1800 www.ok.gov/nursing INSTRUCTIONS for RE-WRITING the LICENSURE EXAMINATION APPLICATION FEE - More information PLEASE NOTE: If a pending application is older than one year from the date submitted and the applicant wishes to
Rev 07/15 STATE BOARD OF EXAMINERS IN SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY P O BOX 2649 HARRISBURG, PA 17105 717-783-1389 www.dos.pa.gov/speech st-speech@pa.gov Application instructions for Licensure More information BOARD OF MEDICINE APPLICATION MATERIALS FOR INITIAL REGISTRATION & RENEWAL OF INTERN/RESIDENT/FELLOW & HOUSE PHYSICIAN PURSUANT TO 458.345, F.S.
BOARD OF MEDICINE APPLICATION MATERIALS FOR INITIAL REGISTRATION & RENEWAL OF INTERN/RESIDENT/FELLOW & HOUSE PHYSICIAN PURSUANT TO 458.345, F.S. DEPARTMENT OF HEALTH 1 TABLE OF CONTENTS SECTION I: Application More information Applicants will be notified within 15 working days of receipt of a completed application as to the status of the application.
2/09, 03/11, 11/11, 01/13, 01/15 Page 1 of 10 MONTANA BOARD OF RADIOLOGIC TECHLOGISTS 301 SOUTH PARK, 4TH FLOOR PO BOX 200513 HELENA, MONTANA 59620-0513 (406) 841-2202 FAX: (406) 841-2305 email: dlibsdrts@mt.gov More information CERTIFICATE OF AUTHORITY (COA) INSTRUCTIONS AND REQUIREMENTS FAQ S
CERTIFICATE OF AUTHORITY (COA) INSTRUCTIONS AND REQUIREMENTS Eligibility for a COA to practice as a Certified Nurse Midwife (CNM), Certified Nurse Practitioner (CNP), Certified Nurse Specialist (CNS) or More information Application Checklist of Requirements for Interior Design Certification (N.J.S.A. 45:3-38)
New Jersey Office of the Attorney General Division of Consumer Affairs New Jersey State Board of Architects Interior Design Examination and Evaluation Committee 124 Halsey Street, 3rd Floor, P.O. Box 45001 More information 2016 © DocPlayer.net Privacy Policy | Terms of Service | Feedback