NYSED Office of the Professions - Registered Nurse - Application

Registered Nurse Form 1 Application is Submitted for Review

Please Fill out the form with complete information

*Contact Information

*Do you have a Social

*Security Number?

Yes ____________________
No
*Date of Birth: ______________________

NYS DMV ID

*Full Name:
If Married (Maiden Name):

*Current Address (Include Postal Code):

*Permanent Address (Include Postal Code):

*Phone/Mobile Number:

*E-Mail Address (Personal):

*Accommodations

* I have been diagnosed as having a disability and require reasonable accommodations and am submitting the Request
for Reasonable Testing Accommodations (https://www.op.nysed.gov/about/general-information-policies#testing)
form. I understand that I will not be able to test until I submit the appropriate documentation and am approved to
test with accommodations.

Yes
No

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*History

* Do you have another name that appears on a degree or other credentials?

Yes
If yes, what are the other names you are using? (Please separate full name with comma)

No

* Have you ever applied for New York State licensure in any profession?

Yes
No

*Moral Character
Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or
misdemeanor) in any court?

Yes
No

-Are criminal charges pending against you in any court?

Yes
No

* Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled,
accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate held
by you now or previously, or ever fined, censured, reprimanded, or otherwise disciplined you?

Yes
No

Are charges pending against you in any jurisdiction for any sort of professional misconduct?

Yes
No

* Has any hospital, licensed facility, or clinical laboratory restricted or terminated your professional training,
employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such
association to avoid imposition of such measures?
Yes
No

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*Examination History

* If you have ever taken the SBPT, NCLEX, or a state-constructed examination for licensure as either a Registered
Professional Nurse or a Licensed Practical Nurse in the United States or its territories (except New York State), please
mark "Yes" below. Otherwise, please select "No".
Yes
No

Previous Nursing Licenses

* Do you hold an RN license in another state or U.S territory?

Yes
No

SBTP, NCLEX, and State-Constructed Examinations

If you have ever taken the SBPT, NCLEX, or a state-constructed examination for licensure as either a Registered
Professional Nurse or a Licensed Practical Nurse in the United States or its territories (except New York State), complete
the following information. If you have taken multiple examinations, click the Add New Exam button to enter details for
additional examinations.

* State or * * Date of * Exam License/Certi cate Number (If

Jurisdiction Profession(s Examination Name Granted)
)

*Elementary or Primary School

Please complete the section below with details about your elementary school(s). If you attended multiple schools, use

the "Add New" button to enter details for additional schools. Any missing information will be considered an
incomplete application.

- Name of School/Issuer

- City

- State/Province

- Country

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- Number of years attended

- Start Date

(Please enter the month and year in MM/YYYY format.)

- End Date

(Please enter the month and year in MM/YYYY format.)

*High School/Secondary School/Equivalency Diploma Issuer

Please complete the section below, responding to the questions presented, about your high school(s) or secondary
school(s) and/or equivalency diploma issuer. If you attended multiple schools, use the “Add New School” button to enter
details for additional schools. Any missing information will cause your application to be considered incomplete."

- Name of School/Issuer

- City

- State/Province

- Country

- Number of years attended

- Start Date

(Please enter the month and year in MM/YYYY format.)

- End Date

(Please enter the month and year in MM/YYYY format.)

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Did you graduate?

Yes
No

Type of Diploma or Certificate awarded?

Secondary Course
- Date Diploma or Certificate awarded?

Nursing Program

Please complete the section below using details about your nursing school(s). If you attended multiple schools, use
the "Add New Program" button to enter details for additional schools. Verification of education must be received
directly from the educational institution. If you were educated outside of the U.S, you must submit a copy of your
diploma/degree in the original language.
-Name of School/Issuer

- City

- State/Province

- Country

- Number of years attended

-Have you received this degree/diploma/certificate?

Yes
No

-Start Date

(Please enter the month and year in MM/YYYY format.)

- End Date

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(Please enter the month and year in MM/YYYY format.)

-Major/Concentration

-Bachelor of Science in Nursing

Title of Degree/Diploma/Certificate awarded (in the original language)

Bachelor of Science in Nursing

- Date awarded

(Please enter the month and year in MM/YYYY format.)

*Other Postsecondary Information

Please complete the section below for any additional postsecondary education. If you have multiple schools to report,
use the "Add New School" button to enter details for additional schools. If you have not attended any additional schools,
click "Remove School". Verification of education must be received directly from the educational institution. If you were
educated outside of the U.S, you must submit a copy of your diploma/degree in the original language. Please refer to the
instructions for Registered Nursing Form 2 (http://www.op.nysed.gov/prof/nurse/nurseforms.htm).

- Name of School/Issuer

- City

- State/Province

- Country

- Number of years attended

- Start Date

(Please enter the month and year in MM/YYYY format.)

- End Date

(Please enter the month and year in MM/YYYY format.)

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- Major/Concentration

- Title of Degree/Diploma/Certificate awarded (in the original language)

- Have you received this degree/diploma/certificate?

Educated Outside of the United States

* Were you educated outside of the United States?

Yes
No

* Do you now hold, or have you ever held, a license or certificate to practice any profession in any state or jurisdiction?

Yes
No

Signature*
Signature over printed name

For reference, the full name on your application is:

Affidavit With Acknowledgment

Applicant

I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I further acknowledge
that I am aware that, pursuant to Penal Law §175.30, a person who knowingly offers a false instrument for filing to a public office or a public servant is guilty
of Offering a False Instrument for Filing in the 2nd Degree, a Class A Misdemeanor. I understand that any false or misleading information in, or in connection
with, my application may be cause for denial or loss of licensure and may result in criminal prosecution.

Type your name below to sign electronically.

Signature*
Signature over printed name

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 NYSED Office of the Professions - Registered Nurse - Application

Child Support Obligation

* Everyone applying for a professional license, permit, or registration, or any renewal thereof, must certify that, as of the
date of the filing, she or he is, or is not, under an obligation to pay child support under section 3-503 of New York
State General Obligations Law. Individuals who are four months or more in arrears in child support or who have
failed to comply with a summons, subpoena or warrant relating to a paternity or child support
proceeding may be subject to suspension of their business, professional, drivers and/or recreational
licenses and permits. The intentional submission of false written statements for the purpose of frustrating or
defeating the lawful enforcement of support obligations is punishable under section 175.35 of the Penal Law.

You must complete this section before we can issue the credential for which you have applied. Individuals who are not in
compliance with their obligation to pay child support can be issued a credential for no more than six months in order to
comply with their child support obligations.

Are you under any obligation to pay child support?

I am not under an obligation to pay child support

I am under an obligation to pay child support

Citizenship/Immigration Status

* Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional
licenses, registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and
Commissioner's regulation, you must complete this section of this form and check the appropriate box below which
indicates your citizenship/immigration status.

A United States citizen or National.

An alien lawfully admitted for permanent residence in the United States.
An alien granted asylum under Section 208 of the Immigration and Nationality Act.
A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a
period of at least 1 year.
An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in
effect prior to April 1980.
Non-Immigrant (Temporarily in U.S.).
An alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood

Arrivals (DACA) relief or similar relief from deportation.

I do not reside in the United States.

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Gender and Ethnicity

Information on gender and ethnicity is sought solely to allow the New York State Education Department to collect and
analyze data concerning diversity in the licensed professions. The ethnic and gender data you provide will be used only
for statistical, research, and program evaluation purposes. It will not be released to the public. This information has
absolutely no bearing on your qualification for licensure.

* What is your gender?

Male

Female

- No Response What is your ethnicity?

White (not Hispanic)
Black (not Hispanic)
Asian
Hispanic
Native American
No Response

Education Program Review

Note:

Fields marked with an asterisk (*) are required.

I give permission to the New York State Education Department to release my examination results to my professional
school for the confidential purposes of program review and institution research and planning. I may rescind this authority
at any time by notifying the Division of Professional Licensing Services in writing.

Education Program Review*

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Education Program Review Acceptance

Signature*
Signature over printed name

For reference, the full name on your application is:

Affidavit With Acknowledgment

Applicant

I declare and affirm that the statements made in this application, including accompanying documents, are true,
complete and correct. I further acknowledge that I am aware that, pursuant to Penal Law §175.30, a person who
knowingly offers a false instrument for filing to a public office or a public servant is guilty of Offering a False Instrument
for Filing in the 2nd Degree, a Class A Misdemeanor. I understand that any false or misleading information in, or in
connection with, my application may be cause for denial or loss of licensure and may result in criminal prosecution.

Type your name below to sign electronically.

Signature*
Signature over printed na

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