STATE OF TENNESSEE DEPARTMENT OF HEALTH HEALTH RELATED BOARDS 227 FRENCH LANDING, SUITE 300 HERITAGE PLACE, METRO

CENTER NASHVILLE, TN 37243

TENNESSEE BOARD OF NURSING 615-532-5166 or 1-800-778-4123

FEES ARE NON REFUNDABLE
INSTRUCTIONS REGISTERED NURSE FOR LICENSURE BY ENDORSEMENT

Please allow 4 to 6 weeks with a Cogent scanned criminal background check or 10 to 12 weeks with a fingerprint card criminal background check to process your application. If additional information is required you will be notified by mail. It is not necessary to call the board to check on the status of your application, go to: tennessee.gov/health, click on Health Care Professionals and then click on verification. Licensure by endorsement in Tennessee is granted on an individual basis. With the exception of a person licensed during the initial waiver period in another U.S. jurisdiction (state), an applicant must be a graduate of an approved school of registered nursing and licensed by written examination. o An applicant shall have general education equivalent to that required for Tennessee candidates for licensure by examination at the time the applicant was accepted for licensure in another jurisdiction. An applicant shall have graduated from an approved school of practical nursing. An applicant shall have substantially the same course of study as set by the Board for Tennessee schools of registered nursing at the tL.111e applicant was accepted for licensure by examination in another jurisdiction. the The Tennessee Board of Nursing accept" the State Board Test Pool Examination (SBTPE) or The National Council Licensure Examination (NCLEX-PN) provided scores are equal to or higher than the lowest passing scores required by this Board. STATE

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APPLICA.c~TS RESIDING IN A COMPACT

Please read all instructions and determine your Primary State of Residence before completing this applications. If your primary state of residence is a compact state and you hold a valid multi state license you may practice in Tennessee on the multi state privilege to practice. If you change your primary state of residence to Tennessee you may practice in Tennessee for up to 30 days. DEFINITION: "PRIMARY STATE OF RESIDENCE" means the state of a person's declared fixed permanent and principle home for legal purposes; domicile. The following items may be requested as proof of primary state of residence: driver's license, voter registration card, federal income tax return, It is recommended that vou begin the application process before moving to Tennessee. FOR A CURRENf LIST OF STATES IN THE COMPACT, CHECK THE FOLLOWING WEB SITE: link to the Nurse Licensure Compact Map. To apply for licensure, submit the following: 2. 3. APPLICA nON. Complete all sections. (Use your full legal name) Affix one (1) professional a) b) c) d) 4. passport type (2W' x 2W') photograph.
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Vending machines, snapshots or ID photographs are not acceptable. Straight on pose including head and shoulders. Full legal name signature and date on front of photograph - signature must not conceal face, no "nicknames". Date the photograph was taken must be no more than six months prior to date of application.

Sign Affidavit at the bottom of page 3 in the presence of a Notary Public. (Use your full legal name) Attach a copy of your nursing diploma or nursing transcript.

5.

JH/GS08600S/BN Revised 11/1 0

10. Graduates of Foreign Nursing School or (CG}'NS) ~- 0 0 0 0 0 0 8. 9.-~. mail the document entitled REQUEST FOR VERIFICATION OF LICENSE TO THE LICENSING AGENCY IN THE STATE WHERE YOU WERE ORIGINALLY LICENSED.._----_ _---. COMPLETION REMINDER: YES 1.---------. NO permit or license will be issued until the results of the criminal background check and verification from original state of license has been received.. Check or money order must be made payable to the Tennessee Board of Nursing..00 7. Copy of your nursing diploma or nursing transcript (copy of intemet transcript is not accepted) 6. Register for and complete criminal background check.--~ If you change your address. Therefore it most cases. __ . Attach the correct fee in U. TO THE BOARD ARE NOT REFUNDABLE TEMPORARY PERMIT: If you have a current active license. If you change your name. LICENSURE FEE.~ --~ I I Foreign Internationally a) b) Copy of Certificate School transcript educated nurses should also include: from Commission 011 7.. VERIFICATION FORM 9. 3. Please supply your full name (as licensed).. IT IS UNPROFESSIONAL CONDUCT TO PRACTICE NURSING IN THE STATE OF TENNESSEE WITHOUT Ai~ ACTIVE REGISTERED NURSE LICENSE OR A MULTI-STATE PRIVILEGE TO PRACTICE FROM ANOTHER COMPACT STATE. telephone number and web sites. The permit is valid for six (6) months and non renewable.:.6. it is your responsibility to notify this office. If you were originally licensed in one of the states not listed on NURSYS Website.. Go to .:-'-'-'-'-''''=~=''''' and click on boards of nursing contact information for board address. currency. Please contact the Board if you have not received a license within four (4) months from the date of application. $115.cogentid. Some states charge a fee for this service. In most cases a permit will not result in authorization to practice sooner than without one.--------------_-. 0 0 --. 0 0 0 5.signed and dated on the front with full legal name signature Verification form sent to state of original licensure or NURSYS verification -_. FEES SUBMITTED 8. current address and original license number so that your records can be readily located. Requested court records (if applicable) Criminal Background Check --.--. A permit can not be issued until the veriflcation has been received. you may request a temporary permit by calling the board office. This permit allows you to practice nursing while the endorsement process is being completed._ .S. For a temporary permit.------ ~~ 4. Go to W\vw..- 0 0 0 0 0 0 -~ I Licensure and Regulatory Fee ($11S_()0) Photograph -. .tn . If you have not worked in nursing for five (5) or more years you will be sent additional instructions. If you were originally licensed in one of the states listed on the NlJRSYS Website use the Website for license verificati on. you must submit a copy of the legal document that changed your name. A temporary permit can not be issued until the results or the criminal background check and verification from original state of license has been received. a permit will not result in authorization to practice sooner than without one. Your application is not complete and you cannot be issued a license until the completed verification form is received by the Tennessee Board of Nursing. The licensing agency will complete the form and return it directly to this office. JH!G508600S/BN Revised 11/10 2 . COMPETENCY REQUIREMENTS/REFRESHER COURSE. APPLICATION NO Completed application form (notarized) -----" 0 ~~ ~-----"._. contact the board office to request a Permit Application I---. Fax to (615) 741-7899.

Specify _ =:- Mailing Address: (Street/PO BoxJR.2 10. Use legal full name FIRST MIDDLE MAIDEN 1.$105.00 1703006-$ 10. _ STATE Completion Date __ 10. If you indicated another compact state as your primary state of residence. Place of Birth __ Ethnic Group: ---::--:-:__ Date of Birth Gender: 0 Female 0 Male City State 0 White 0 Black 0 Native American Indian 0 Asian 0 Hispanic 0 Other. 2.ED. federal income tax return. but will be moving to Tennessee and declaring Tennessee as your primary state of residence please indicate: YES 0 and expected date ofmove _ 8. 5. CONTACT AS A REGISTERED NURSE IN TENNESSEE? THIS OFFICE. General Education: High School Graduate G. Print or Type Please refer to instruction sheet when completing the application.oute) Street Address: --:--:-:-_-. Name LAST List any other names by which you have been known LAST FIRST Telephone Number MIDDLE Social Security Number 3. TN 37243 1703001 .---=-::-:::--:----:::---:(required if Mailing Address is a PO Box) Street (City/State/Zip) =-:-:--::::-:-:--:=-. 6.1 Name of College/University/Schoolof Nursing Location __ --:::-:=-:CITY Length of Program Date of Enrollment 9.3 In what state were you originally licensed as a Registered Nurse? State Date How were you licensed in the original state of licensure? Indicate all states where you have been licensed License No.2 Degree =-=-=::-- o Baccalaureate ~ 0 Associate o Diploma o Master . Nursing Education: 9. Equivalency DYes DYes 0 No 0 No Date of Diploma Date Test Administered _ _ 9. Metro Center Nashville. 4.00 $115. voter registration card. The following items may be requested as proof of primary state of residence: driver's license.1 10._ (City/State/Zip) 7.PHOTOGRAPH NOT TO EXCEED 2%"x2% " PASSPORT TYPE ATTACH PHOTOGRAPH HERE SIGNED AND DATED ON THE FRONT BY APPLICANT USING LEGAL SIGNATURE Date taken must be no more than six months prior to application date Application for Licensure Tennessee Board of Nursing 227 French Landing.00 as a Registered Professional Nurse by Endorsement DYES D NO HAVE YOU EVER BEEN LICENSED IF YES. HOME OFFICE Your social security number may be used to verify your identity and for any other purpose allowed by state or federal law. _ o Examination 0 Endorsement 0 Waiver _ PH#0291 Revised 11/10 1 S 836-1 . This state is referred to as my home state under the Nurse Licensure Compact and means that it is my declared fixed permanent and principle home for legal purposes and is my domicile. suite 300 Heritage Place. ALL FEES ARE NON REFUNDABLE TO BE COMPLETED IN INK BY APPLICANT ALL QUESTIONS MUST BE COMPLETED. Original Registered Nurse Licensure 10. DO NOT COMPLETE THIS FORM. PRIMARYSTATEOF RESIDENCE I declare that my primary state of residence is .

4 16. probation. Are you currently in good physical and mental health? (Include any physical or mental limitations) please explain: Conviction of _ 15. please identify the state where the action was originally taken and provide a certified copy of the documentation that cleared the action. placed on probation or reprimanded) or voluntarily surrendered in any state or jurisdiction?D YES D NO If yes. What is your anticipated nursing position in Tennessee? POSITION Name and complete mailing address of prospective employer (if known) 18. please identify _ 13. Check only one.1 16._9_~ 16.5 ------- ------------------------------------ ----------------------------------------------------17. 12. List employment as a registered nurse during the last five years. and a self letter that describes circumstances that resulted in arrest and conviction. STATE YEAR _ DYes 0 No Ifno. 13. Please Specify (10) (14) Revised 11/10 2 S 836-1 . please indicate State Date _ Month/Day/Y ear Some states offered either a state constructed examination for licensure or the national licensing examination. o o 19. suspended. If yes.P. What is your activity (work) status in the nursing profession? (Working in this profession also includes teaching. administration and research). specify date and type of conviction.T.11. please submit a certified copy of the warrant and judgment or conviction papers and evidence of completion of fines.) and is currently known as the National Council Licensure Examination (NCLEX-RN). THIS QUESTION MUST BE ANSWERED Mailing Address (City and State) RN Position Employerl Agency H_~~ Employment Dates (MonthlYear) Beginn!ng/En=di:.1 Have you ever been convicted of or pled guilty to a misdemeanor or felony other than a minor traffic violation? DYes D No If yes. a Crime 15. D= = = Working full time in Nursing (1) Working part time in Nursing (2) Not worked in Nursing for less than 2 years (3) 0 0 = = o = Not worked less than 5 Not worked Official Use in Nursing for at least 2 years but years (4) in Nursing for 5 years or more (5) Only (6) Please indicate your major practice area in nursing: Check Only One o o o o o o = o o PH#0291 = = = Community/Public Health (1) General Practice (2) Geriatric (3) Obstetric/Gynecologic (4) Medical/Surgical (5) Pediatric (6) Psychiatric/Mental Health (7) Critical/Intensive Care (8) o o o o o o = = = o Emergency Service (9) Case Management (11) Primary Care (12) Education (13) Administrative/Management Perioperative (15) Other.E. 16. The national licensing examination was previously known as the State Board Test Pool Examination (S.2 14.B..3 16.1 Action DYES DNO If yes.2 Type of Conviction _ COMPLETELY. Date --:--:--~=---::-:---------Month/Day/Y ear 15. Have you taken a national licensing examination? DYes D No If yes.:_::"_. restitution. certificate or privilege or registration disciplined (revoked.2 16. Have you ever been licensed in any other health care profession? profession and state Disciplinary 13. Have you ever been denied a nursing license or had any other professional license.

FreeStanding Surgery Center (2) Office (Physician or Dentist) (3) Nursing Home (4) Home Health (5) Private Duty (6) Insurance (7) = =: =: =: =: Hospice (13) School Nurse (11) School of Nursing/College/ University (12) Assisted Living/Home for the Aged (15) Other. me this day of Notary Public . =: =: Diploma (1) Associate degree in Nursing (2) Bachelor's in Nursing (3) o o = Master's in Nursing (4) =: Doctorate in Nursing (5) Check Only One Please indicate your highest degree in another field.. I understand he/she that if the processing of this application is not completed.:::--:-:::::::-:-:::-:::-:::NAMEOF APPLICANT _ personally appearing before me. Legal Signature of Applicant _ Sworn to before. Please specify (10) _ Please indicate your current type of nursing position Check Only One o o = =: =: o o o o o o =: o =: =: Administrator (1) Consultant (2) Supervisor or Assistant (3) Instructor or Educator (4) Head Nurse or Assistant (5) Staff or General Duty (6) Nurse Anesthetist (17) Nurse Anesthetist (Certified) (9) Nurse Practitioner (7) 0 0 =: =: =: =: =: =: =: =: 0 0 0 0 0 0 Nurse Practitioner (Certificate of Fitness to prescribe) (12) Clinical Specialist (8) Clinical Specialist (Certificate of Fitness to prescribe) (13) Nurse Midwife (Certified) (10) Nurse Midwife (Certificate of Fitness to prescribe) (14) Quality Assurance (15) Case Manager (16) Other. the application becomes null and void one year from date received.. Please indicate your principal setting of Employment: Check Only One 0 = Industrial/Occupational (8) 0 = Community/Public Health (9) 0 0 0 0 0 o o o o o o o 21. if applicable: o o o =: No Other Degree Held (6) Associate (7) Bachelor'S (8) 0 0 =: =: Master's (9) Doctorate (10) AFFIDAVIT State of ------------------County of _____ ----:-:-:-:-:. please specify (11) 22. I also understand that falsification of an application is grounds for denial of licensure or discipline against a license. being duly sworn says that he/she - is the person referred to in the foregoing application for a license to practice as a Registered Nurse in the State of Tennessee that the statements therein contained are true and that has read and understands this affidavit. =: =: =: Hospital/Medical Center (1) Ambulatory/Outpatient Clinic. 20 _ _ _ Seal Commission Expires PH#0291 Revised 11/10 3 S 836-1 . Please indicate your highest degree in nursing: Check Only One n o o 23.-.20.

LICENSE NO. __ DATE ISSUED _ DATEISSUED _ DATE EXPIRED __ _ _ PH#0291 Revised 11/10 4 S 836-1 .FOR OFFICE USE ONLY NAME PERMIT NO.

Suite 300 Heritage Place Metro Center Nashville. Revised 11/30/2010 . please contact the TN Board of Nursing 615-532-5166. go to https:\\www.com and follow the instructions there. Contact the initial state of licensure for information of their fees for verification. Only boards of nursing within the United States have access to Nursys®. Alaska (AK) Arizona (AZ) Arkansas (AR) Colorado (CO) Delaware (DE) District of Columbia (DC) Florida (FL) Idaho (ID) Indiana (IN) Iowa (IA) Kentucky (KY) Louisiana (LA)-RN Maine (ME) Maryland (MD) Massachusetts (MA) Minnesota (MN) Mississippi (MS) Missouri (MO Nebraska (NF) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) North Carolina (NC) North Dakota (ND) Ohio (OB) Oregon (OR) Rhode Island (Rr) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (V A) Virgin Islands Washington (WA) West Virginia(WV)PN Wisconsin (WI) Wyoming (WY) 3. 4. If you have questions regarding the Nursys verification process. TN 37243 tennessee. 6. the board will access Nursys to verify your original licensure in one ofthe states listed in number 2 above. This form is sent to the state of initial licensure. usc the form and verification instructions included with the on-line or paper endorsement packet. The fee for on-line verification through Nursys is $30. Fees need to be sent with the verification form. If your original state oflicensure was from one of the states listed below. When the Tennessee Board of Nursing receives your Endorsement Application. 5.gov/health NURSYS VERIFICATION INSTRUCTIONS 1. please contact the Nursys License Verification Department at (312) 525-3780 or toll free (866) 819-1700. ONLY if your initial licensure was in a state not listed in number 2 above. It is processed on-line through Nursys. If you need verification of a license for a foreign country. Nursys information is updated from the files of participating states.STATE OF TENNESSEE DEPARTMENT OF HEALTH BUREAU OF HEALTH LICENSURE AND REGULATION DIVISION OF HEALTH RELATED BOARDS 227 French Landing. If you do not need verification of a license from one of the states listed below use the form provided with the endorsement or on line packet.nursys. A nurse who recently received a license may have to wait until the next update before the information is available in Nursys. 2. 7.

restricted. DATE ISSUED: Board of Nursing to furnish to the Tennessee Board of Nursing the information requested below.N. DATE SIGNATURE DO NOT WRITE BELOW THIS LINE-FOR LICENSING AGENCY ONLY This is to certify that the above named was issued license number to practice as a: _ date: Q Registered Nurse Q Licensed Practical Nurse on Licensed by: Q Examination Active a Endorsement a Waiver a Expiration Inactive Not Current Current licensure status: Has this license ever been encumbered in any way (revoked.P. NAME WHEN ORIGINALLY ADDRESS: (street) LICENSED: (last) (first) (middle) (maiden) (city) (state) (zip) NURSING EDUCATION PROGRAM COMPLETED: _ ORIGINAL LICENSE NUMBER: SOCIAL SECURITY NO. (05/08) a Yes Q No _ _ __ SEAL STATE DATE RDA-1786 . Q L. Metro Center Nashville. TN 37243 REQUEST FOR VERIFICATION APPLICANT: NAME: (last) (first) (middle) (maiden) OF LICENSE Complete the top part of this page and forward it to the state in which you were ORIGr~_A_ILY licensed. NCLEX RN Surgical Nursing Nursing of Children NCLEX LPN STATE BOARD TEST POOL EXAMINATION Medical Nursing Standard Scores Series! Form Nursing education program completed: (name) Psychiatric Nursing Obstetric Nursing Location: (city) (state) Year of graduation _ Was nursing education program approved by Board of Nursing at time of graduation? SIGNED TITLE JHlG5022133/BN PH-2384 Rev. please explain on reverse side. surrendered. placed on probation)? Yes a No [J1 If yes.N.Tennessee Department of Health Health Related Boards Tennessee Board of Nursing 227 French Landing. suite 300 Heritage Place. limited. suspended.: I hereby authorize the (state to which sending form) Q R.

tn and click on Cogent Fingerprint Services. 1. Payment for electronic fingerprint scan is $48.00. Online registration is preferred fix ALL applicants to insure the quality of the data collected.!..gov/health CRIMINAL BACKGROUND CHECK INSTRUCTIONS FOR APPLICANTS Applicants who do not live in Tennessee and not visiting Tennessee prior to licensure may call their licensure board 615-532-5166 and request a fingerprint card and the instructions for processing. TN 37243 tennessee.:.!!.!". the following information must be provided: ORI# Transaction type Originating Case Number COCA) Payment Type TN920390Z BH-DILPARTMENT OF HEALTH TCA 63-1-116 RN enter (1703) LPN enter (1704) Applicant Credit Card/Applicant Money Order 2.~~!l. Regardless of how an applicant registers. Effective June 1. CASH is NOT accepted. 7 days a week. under Useful Links. click on TN Department of Health.!.I!.free at (877) 862-2425 b) Register online at www. 2006 applicants for initial licensure in Tennessee (not renewal or reinstatement) must obtain a criminal background check through the State of Tennessee selected vendor. Electronic print locations are available at ~~:.~~~.. Electronic Fingerprints are normally received by the Tennessee Health Related Boards within 8-10 business days. Suite 300 Heritage Place Metro Center Nashville.!. but must wait to be scanned until the day after they register.'!'!: at Print Locations.cogentid. 3. Applicants can then have their fingerprints scanned at any COGENT Systems locations. COGENT Systems. Applicants must show valid state or federal government issued photo identification and must make known their social security number to Cogent Systems when they visit the fingerprint scanning location. Applicants may obtain a receipt of the fingerprint submission. There are (2) ways that applicants may register for the fingerprint scanning: a) Call the Tennessee Registration Line toll... Online registration is faster and may be completed 24 hours a day.!.STATE OF TENNESSEE DEPARTMENT OF HEALTH BUREAU OF HEALTH LICENSURE AND REGULATION DIVISION OF HEALTH RELATED BOARDS 227 French Landing. Applicant may register for fingerprinting and make payment at this web site. an appointment is not necessary. 4. modify their registration information prior to fingerprinting and obtain a payment refund prior to fingerprinting at this web site. JH 11116/2010 . Once an applicant is registered.!2~~.:JJ. Money orders or cashier checks made out to Cogent Systems are also accepted at the fingerprint service sites. To begin registration.

TN Enclose a non-refundable money order or cashiers check for $60. sex. 4. PLEASE DO NOT BEND OR FOLD THE FINGERPRINT CARD JH 10/26/2010 . Suite 300 Heritage Place. 7. 3. Boxes requesting date of birth. race. which starts when received at TBI Headquarters. place of birth. 6. weight. SUITE 300 HERITAGE PLACE. Request a fingerprint card from your local law enforcement office and follow instructions below.00 and make payable to the Tennessee Bureau of Investigation Personal checks and cash are not accepted Have your prints completed by a qualified technician. write in the name and address of your licensing board TN Board of Nursing 227 French Landing. In the box asking for the employer and address. TN 37243 TENNESSEE BOARD OF NURSING 615-532-5166 or 1-800-778-4123 FINGERPRINT CARD INSTRUCTIONS All applicants applying for initial licensure in Tennessee (not renewal or reinstatement) must obtain a criminal background check through the Tennessee Bureau of Investigation. at a local police or sheriff office. METRO CENTER NASHVILLE.S. write in the applicable profession Registered Nurse enter (1703) Licensed Practical Nurse enter (1704) In the box asking for the ORT number write in TN 920390Z BUR HLTHILIC-REG/vCA NASHVILLE.STATE OF TENNESSEE DEPARTMENT OF HEALTH HEALTH RELATED BOARDS 227 FRENCH LANDING. 5. Mail the completed fingerprint card and your non-refundable payment after completion to: TBI-Records & Identification Unit Applicant Processing 901 R. Fill out the fingerprint card legibly. eyes and hair must to be completed. the applicant shall be required to come to the State of Tennessee and submit a TBI/FBI fingerprint scan through the State of Tennessee's approved vendor COGENT Systems. height. Prints rejected due to poor quality could extend processing time. TN 37243 In the box asking for the reason fingerprinted.Gass Boulevard Nashville. Current processing time is 4-6 weeks. 8. 1. write in: BH-DEPARTMENT OF HEALTH TCA 63-1-116 In the box asking for your OCA number. Prints must be rolled nail to nail 2. Metro Center Nashville. TN 37216-2639 In all cases where an applicant's fingerprint cards (8) are rejected 2 or more times.

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