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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
o o 1.
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.
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.
JH/GS08600S/BN Revised 11/1 0
COMPETENCY REQUIREMENTS/REFRESHER COURSE. mail the document entitled REQUEST FOR VERIFICATION OF LICENSE TO THE LICENSING AGENCY IN THE STATE WHERE YOU WERE ORIGINALLY LICENSED. If you were originally licensed in one of the states listed on the NlJRSYS Website use the Website for license verificati on.- 0 0 0 0 0 0 -~ I Licensure and Regulatory Fee ($11S_()0) Photograph -.._. 10. a permit will not result in authorization to practice sooner than without one._ . you may request a temporary permit by calling the board office.--. 0 0 --. If you have not worked in nursing for five (5) or more years you will be sent additional instructions. VERIFICATION FORM 9. 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. If you were originally licensed in one of the states not listed on NURSYS Website. Please contact the Board if you have not received a license within four (4) months from the date of application.-~. $115._----_ _---. For a temporary permit. Go to W\vw.6. currency. Attach the correct fee in U. Copy of your nursing diploma or nursing transcript (copy of intemet transcript is not accepted) 6... Some states charge a fee for this service.:. Check or money order must be made payable to the Tennessee Board of Nursing.------ ~~ 4. 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. LICENSURE FEE.cogentid.. telephone number and web sites. it is your responsibility to notify this office. COMPLETION REMINDER: YES 1.--------------_-..signed and dated on the front with full legal name signature Verification form sent to state of original licensure or NURSYS verification -_. 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.. The licensing agency will complete the form and return it directly to this office. APPLICATION NO Completed application form (notarized) -----" 0 ~~ ~-----".00 7. FEES SUBMITTED 8. The permit is valid for six (6) months and non renewable.~ --~ I I Foreign Internationally a) b) Copy of Certificate School transcript educated nurses should also include: from Commission 011 7. In most cases a permit will not result in authorization to practice sooner than without one.tn . Go to . JH!G508600S/BN Revised 11/10 2 . 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. __ . Graduates of Foreign Nursing School or (CG}'NS) ~- 0 0 0 0 0 0 8. Fax to (615) 741-7899. . contact the board office to request a Permit Application I---. Please supply your full name (as licensed). current address and original license number so that your records can be readily located. If you change your name. 3. TO THE BOARD ARE NOT REFUNDABLE TEMPORARY PERMIT: If you have a current active license.S.---------. 0 0 0 5. A permit can not be issued until the veriflcation has been received. This permit allows you to practice nursing while the endorsement process is being completed..:-'-'-'-'-''''=~=''''' and click on boards of nursing contact information for board address.--~ If you change your address. 9. you must submit a copy of the legal document that changed your name. Requested court records (if applicable) Criminal Background Check --. Therefore it most cases. Register for and complete criminal background check.
Print or Type Please refer to instruction sheet when completing the application. 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.00 1703006-$ 10. 5.2 10. _ o Examination 0 Endorsement 0 Waiver _ PH#0291 Revised 11/10 1 S 836-1 . 2. General Education: High School Graduate G. Original Registered Nurse Licensure 10. voter registration card.---=-::-:::--:----:::---:(required if Mailing Address is a PO Box) Street (City/State/Zip) =-:-:--::::-:-:--:=-.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. suite 300 Heritage Place.1 10.3 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. HOME OFFICE Your social security number may be used to verify your identity and for any other purpose allowed by state or federal law. CONTACT AS A REGISTERED NURSE IN TENNESSEE? THIS OFFICE. _ STATE Completion Date __ 10. Name LAST List any other names by which you have been known LAST FIRST Telephone Number MIDDLE Social Security Number 3. Metro Center Nashville. ALL FEES ARE NON REFUNDABLE TO BE COMPLETED IN INK BY APPLICANT ALL QUESTIONS MUST BE COMPLETED. 6.1 Name of College/University/Schoolof Nursing Location __ --:::-:=-:CITY Length of Program Date of Enrollment 9. 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._ (City/State/Zip) 7.2 Degree =-=-=::-- o Baccalaureate ~ 0 Associate o Diploma o Master . but will be moving to Tennessee and declaring Tennessee as your primary state of residence please indicate: YES 0 and expected date ofmove _ 8. Equivalency DYes DYes 0 No 0 No Date of Diploma Date Test Administered _ _ 9. 4.00 $115.oute) Street Address: --:--:-:-_-. The following items may be requested as proof of primary state of residence: driver's license. Specify _ =:- Mailing Address: (Street/PO BoxJR. Nursing Education: 9. DO NOT COMPLETE THIS FORM. federal income tax return. PRIMARYSTATEOF RESIDENCE I declare that my primary state of residence is .ED. Use legal full name FIRST MIDDLE MAIDEN 1.$105.00 as a Registered Professional Nurse by Endorsement DYES D NO HAVE YOU EVER BEEN LICENSED IF YES. TN 37243 1703001 .
suspended. The national licensing examination was previously known as the State Board Test Pool Examination (S. probation. Have you ever been licensed in any other health care profession? profession and state Disciplinary 13. o o 19. Date --:--:--~=---::-:---------Month/Day/Y ear 15. What is your activity (work) status in the nursing profession? (Working in this profession also includes teaching. placed on probation or reprimanded) or voluntarily surrendered in any state or jurisdiction?D YES D NO If yes. certificate or privilege or registration disciplined (revoked. If yes. 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._9_~ 16.2 14.P. please indicate State Date _ Month/Day/Y ear Some states offered either a state constructed examination for licensure or the national licensing examination. restitution. please identify _ 13.2 16. Have you taken a national licensing examination? DYes D No If yes.. Are you currently in good physical and mental health? (Include any physical or mental limitations) please explain: Conviction of _ 15. 16.5 ------- ------------------------------------ ----------------------------------------------------17.E.1 Action DYES DNO If yes. What is your anticipated nursing position in Tennessee? POSITION Name and complete mailing address of prospective employer (if known) 18. a Crime 15.) and is currently known as the National Council Licensure Examination (NCLEX-RN). specify date and type of conviction. 13. Have you ever been denied a nursing license or had any other professional license. Check only one.2 Type of Conviction _ COMPLETELY.T.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. 12.4 16. THIS QUESTION MUST BE ANSWERED Mailing Address (City and State) RN Position Employerl Agency H_~~ Employment Dates (MonthlYear) Beginn!ng/En=di:.11. List employment as a registered nurse during the last five years. STATE YEAR _ DYes 0 No Ifno. administration and research).B.:_::"_. please submit a certified copy of the warrant and judgment or conviction papers and evidence of completion of fines. and a self letter that describes circumstances that resulted in arrest and conviction.1 16. Please Specify (10) (14) Revised 11/10 2 S 836-1 .3 16. please identify the state where the action was originally taken and provide a certified copy of the documentation that cleared the action.
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. =: =: =: Hospital/Medical Center (1) Ambulatory/Outpatient Clinic.. me this day of Notary Public . 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 _____ ----:-:-:-:-:. 20 _ _ _ Seal Commission Expires PH#0291 Revised 11/10 3 S 836-1 . =: =: 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.. 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. I understand he/she that if the processing of this application is not completed. 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. please specify (11) 22.-. Please indicate your highest degree in nursing: Check Only One n o o 23.20. 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.:::--:-:::::::-:-:::-:::-:::NAMEOF APPLICANT _ personally appearing before me. I also understand that falsification of an application is grounds for denial of licensure or discipline against a license.
__ DATE ISSUED _ DATEISSUED _ DATE EXPIRED __ _ _ PH#0291 Revised 11/10 4 S 836-1 . LICENSE NO.FOR OFFICE USE ONLY NAME PERMIT NO.
This form is sent to the state of initial licensure. Only boards of nursing within the United States have access to Nursys®. TN 37243 tennessee. A nurse who recently received a license may have to wait until the next update before the information is available in Nursys. please contact the TN Board of Nursing 615-532-5166. usc the form and verification instructions included with the on-line or paper endorsement packet. Revised 11/30/2010 .com and follow the instructions there.gov/health NURSYS VERIFICATION INSTRUCTIONS 1. Fees need to be sent with the verification form. Contact the initial state of licensure for information of their fees for verification.STATE OF TENNESSEE DEPARTMENT OF HEALTH BUREAU OF HEALTH LICENSURE AND REGULATION DIVISION OF HEALTH RELATED BOARDS 227 French Landing. 6. the board will access Nursys to verify your original licensure in one ofthe states listed in number 2 above. 2. 7. 4. Nursys information is updated from the files of participating states. please contact the Nursys License Verification Department at (312) 525-3780 or toll free (866) 819-1700. 5. When the Tennessee Board of Nursing receives your Endorsement Application. ONLY if your initial licensure was in a state not listed in number 2 above. 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. 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. Suite 300 Heritage Place Metro Center Nashville. It is processed on-line through Nursys. If you need verification of a license for a foreign country. If you have questions regarding the Nursys verification process.nursys. The fee for on-line verification through Nursys is $30. If your original state oflicensure was from one of the states listed below. go to https:\\www.
Tennessee Department of Health Health Related Boards Tennessee Board of Nursing 227 French Landing. NAME WHEN ORIGINALLY ADDRESS: (street) LICENSED: (last) (first) (middle) (maiden) (city) (state) (zip) NURSING EDUCATION PROGRAM COMPLETED: _ ORIGINAL LICENSE NUMBER: SOCIAL SECURITY NO. Metro Center Nashville.P.: I hereby authorize the (state to which sending form) Q R. suspended. restricted. placed on probation)? Yes a No [J1 If yes.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. suite 300 Heritage Place. 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. limited. please explain on reverse side. Q L. (05/08) a Yes Q No _ _ __ SEAL STATE DATE RDA-1786 . surrendered.N. DATE ISSUED: Board of Nursing to furnish to the Tennessee Board of Nursing the information requested below. 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.
Applicants may obtain a receipt of the fingerprint submission. Electronic Fingerprints are normally received by the Tennessee Health Related Boards within 8-10 business days.~~!l. There are (2) ways that applicants may register for the fingerprint scanning: a) Call the Tennessee Registration Line toll.!2~~. Once an applicant is registered. Electronic print locations are available at ~~:. Applicant may register for fingerprinting and make payment at this web site.tn and click on Cogent Fingerprint Services. Online registration is preferred fix ALL applicants to insure the quality of the data collected. Payment for electronic fingerprint scan is $48.!. Suite 300 Heritage Place Metro Center Nashville. Online registration is faster and may be completed 24 hours a day. Effective June 1.!".:JJ.I!. 7 days a week. click on TN Department of Health.'!'!: at Print Locations. 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. COGENT Systems. 1.!. Regardless of how an applicant registers. but must wait to be scanned until the day after they register. TN 37243 tennessee. 2006 applicants for initial licensure in Tennessee (not renewal or reinstatement) must obtain a criminal background check through the State of Tennessee selected vendor. an appointment is not necessary.!.cogentid..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. 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. modify their registration information prior to fingerprinting and obtain a payment refund prior to fingerprinting at this web site. JH 11116/2010 . 3.!!. under Useful Links.free at (877) 862-2425 b) Register online at www..!. 4.STATE OF TENNESSEE DEPARTMENT OF HEALTH BUREAU OF HEALTH LICENSURE AND REGULATION DIVISION OF HEALTH RELATED BOARDS 227 French Landing. Money orders or cashier checks made out to Cogent Systems are also accepted at the fingerprint service sites. Applicants can then have their fingerprints scanned at any COGENT Systems locations.:.00. To begin registration. CASH is NOT accepted..~~~..
PLEASE DO NOT BEND OR FOLD THE FINGERPRINT CARD JH 10/26/2010 . Prints must be rolled nail to nail 2. SUITE 300 HERITAGE PLACE. Boxes requesting date of birth. 4. TN Enclose a non-refundable money order or cashiers check for $60. Suite 300 Heritage Place.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. Metro Center Nashville. Mail the completed fingerprint card and your non-refundable payment after completion to: TBI-Records & Identification Unit Applicant Processing 901 R. write in: BH-DEPARTMENT OF HEALTH TCA 63-1-116 In the box asking for your OCA number.Gass Boulevard Nashville. place of birth. sex. METRO CENTER NASHVILLE. race. at a local police or sheriff office. In the box asking for the employer and address. 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. 6. Current processing time is 4-6 weeks. Fill out the fingerprint card legibly. TN 37216-2639 In all cases where an applicant's fingerprint cards (8) are rejected 2 or more times. Request a fingerprint card from your local law enforcement office and follow instructions below. 3.STATE OF TENNESSEE DEPARTMENT OF HEALTH HEALTH RELATED BOARDS 227 FRENCH LANDING. 1. weight. 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. 7. 8. TN 37243 In the box asking for the reason fingerprinted. write in the name and address of your licensing board TN Board of Nursing 227 French Landing. Prints rejected due to poor quality could extend processing time. eyes and hair must to be completed. 5.S. height. which starts when received at TBI Headquarters. 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.
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