Free 50027.FH11 - Indiana

APPLICATION FOR LICENSURE BY ENDORSEMENT AS A NURSE
State Form 50027 (R2 / 2-06) Approved by State Board of Accounts, 2006

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INDIANA STATE BOARD OF NURSING PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2043 E-mail: [email protected] http://www.state.in.us/pla/boards/isbn/

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given.

FOR OFFICE USE ONLY
Application fee Date fee paid (month, day, year) Receipt number License number Issuance date (month, day, year) Permit fee Date fee paid (month, day, year) Receipt number Permit number Issuance date (month, day, year)

DO NOT WRITE ABOVE THIS LINE
R.N. L.P.N.
Do you desire a temporary permit?

Yes

No

If Yes, you must submit the temporary permit fee and proof of CURRENT / ACTIVE licensure in another state, along with the application, picture and fee for the permanent license.
Have you previously filed an application for licensure in the State of Indiana?

Please indicate original state of licensure

Yes

No

APPLICANT INFORMATION
Name (last, first, middle, maiden) Street address (number and street or rural route) Daytime telephone number (include area code) City Date of birth (month, day, year) E-mail address List any other last names ever used State ZIP code Place of birth (city and state)

(

)

Social Security number *

NURSING EDUCATION
Name of nursing school Location (city and state) Date of enrollment (month, day, year) Date of graduation (month, day, year)

CHECK THE TYPE OF PROGRAM FROM WHICH YOU GRADUATED RN PROGRAM Associate Degree (2 year) Baccalaureate Degree (4 year) Diploma (3 year) PN PROGRAM

HIGH SCHOOL EDUCATION
Name of school Location (city and state) Date of graduation (month, day, year) If you are not a high school graduate, have you taken and passed the GED?

Yes

No

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EXAMINATION You are required to have taken and passed one of the following examinations to be eligible for licensure in the State of Indiana. If you took the CNAT or CRNE, it must have been the English version to be accepted. CHECK THE APPROPRIATE EXAMINATION YOU TOOK FOR ORIGINAL LICENSURE. NCLEX-RN
State administering the examination

SBTPE-RN

NCLEX-PN

SBTPE-PN

CNAT / CRNE

Date examination was/will be administered on (month, day, year)

If you took a State Constructed Examination only, you will not be eligible for licensure by endorsement in the State of Indiana.
Do you hold, or have you ever held, a license, certificate, registration or permit to practice nursing and/or any other regulated health occupation?

Yes

No

List all states, including Indiana, in which you hold or have held a license, certificate, registration or permit to practice nursing and/or any other regulated health occupation. If Illinois is your original state of licensure, you must provide us with an official or notarized copy of your diploma or transcripts from your nursing program. LICENSE TYPE STATE NUMBER DATE OF ISSUE STATUS

If your answer is Yes to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held in any state or country? 2. Have you ever been denied a license, certificate, registration or permit to practice as a nurse or any regulated health occupation in any state or country? 3. Are there charges pending against you regarding a violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances, alcohol or other drugs? 4. Have you ever been convicted of, pled guilty or nolo contendre to: A. A violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances, alcohol or other drugs? B. To any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. Have you ever been terminated, reprimanded, disciplined or demoted in the scope of your practice as a nurse or as another health care professional? 6. Have you ever had a malpractice judgment against you or settled any malpractice action? 7. Are you being treated or have you ever been treated for drug or alcohol abuse? APPLICATION AFFIRMATION I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

Yes Yes Yes

No No No

Yes

No

Yes Yes Yes Yes

No No No No

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MANDATORY DISCLOSURE OF U.S. SOCIAL SECURITY NUMBER

Pursuant to Section 7 of the Privacy Act of 1974, you are hereby given notice that disclosure of your U.S. Social Security number on your application is mandatory for the purpose of complying with IC 25-1-5-8 and IC 4-1-8-1 which provide that the Indiana Department of Revenue may obtain Social Security numbers from the Professional Licensing Agency for tax enforcement purposes. In addition, disclosing such number is mandatory in order for the licensing board or committee to comply with the requirements of the federal National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank 42 U.S.C. 1320(a)-7e(b), 5 USC 552a, 45 CFR Part 60.1, and 45 CFR Part 61. Failure to disclose your U.S. Social Security number will result in the denial of your application. Application fees are not refundable.
AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application for licensure as a nurse. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any information. I further authorize the Professional Licensing Agency to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency and the Indiana State Board of Nursing from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original.
AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to the same.
Signature of applicant Date (month, day, year)

PLEASE TAPE YOUR PHOTOGRAPH BELOW (DO NOT STAPLE) (You must place your signature on the front of your photograph.)

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APPLICATION FOR A TEMPORARY PERMIT BY ENDORSEMENT

An applicant for licensure by endorsement may obtain a Temporary Permit to practice nursing in Indiana as a Registered Nurse or a Licensed Practical Nurse. This permit expires at the earlier of ninety (90) days after issuance or upon issuance of a permanent license. This application should be completed only if the applicant is requesting a Temporary Permit. Please provide a copy of your current license in another state with this application.
Name of applicant (last, first, middle) Street address (number and street or rural route) City Social Security number * This is to certify that I have a current, valid license to practice nursing as follows: License number State ZIP code List any other last names ever used

* Your Social Security number is being requested according to IC 4-1-8-1. The request is MANDATORY and this application cannot be processed without it. Registered Nurse Licensed Practical Nurse
State of current licensure

Expiration date (month, day, year)

I further certify that my license is in good standing. I have had no disciplinary action taken on my license and no disciplinary action is pending.
Signature of applicant Date (month, day, year)

APPLICATION AFFIRMATION

I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

SWORN TO AND SIGNED BEFORE ME THIS

NOTARY SEAL

________ DAY OF _________________________, 20________.
Signature of notary public

Expiration date of commission (month, day, year)

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