Free 50023.FH11 - Indiana

APPLICATION FOR LICENSURE BY EXAMINATION FOR GRADUATES OF FOREIGN NURSING SCHOOLS
State Form 50023 (R / 2-06) Approved by State Board of Accounts, 2006

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/

INSTRUCTIONS:

Please type or print clearly and answer all questions.

* 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 License number Date fee paid (month, day, year) Receipt number

Date of issuance (month, day, year)

DO NOT WRITE ABOVE THIS LINE
Are you applying for a license as a: Have you taken the NCLEX examination previously?

Registered Nurse
If Yes, when and in what state?

Licensed Practical Nurse

Yes

No

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

(

)

Social Security number *

NURSING EDUCATION
Name of nursing school Length of program Date of completion (month, day, year) Date of entrance (month, day, year) Date of graduation (month, day, year)

You must submit an OFFICIAL or NOTARIZED copy of your nursing school transcripts, separated into clinical and theory hours or days.
HIGH SCHOOL EDUCATION
Name of school Location Date of graduation (month, day, year) If you are not a high school graduate, have you taken and passed the GED? (If yes, submit an official copy of your GED scores)

Yes
Do you hold, or have you ever held, a license, certificate, registration or permit to practice any regulated health occupation?

No No

Yes

List all states, including Indiana, foreign territories, or countries, in which you hold or have held a license, certificate, registration or permit to practice any regulated health occupation. License Type State / Country / Territory Number Date of Issue Status

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COMMISSION ON GRADUATES OF FOREIGN NURSING SCHOOLS EXAMINATION
Have you taken and passed the Commission on Graduates of Foreign Nursing Schools Examination?

Yes

No

If your answer is Yes, provide the date you took the examination (month, day, year).

The CGFNS must send evidence that you passed the examination directly to the Professional Licensing Agency. If your answer is No, you MUST TAKE AND PASS this examination before taking the registered nurse examination, and have the Commission submit such proof directly to the Professional Licensing Agency. For information regarding the CGFNS examination, please contact:

Commission on Graduates of Foreign Nursing Schools 3600 Market Street, Suite 400 Philadelphia, PA 19104-2651 Telephone: (215) 349-8767 www.cgfns.org
** Applicants who have completed a practical nursing program are not required to take the CGFNS examination.

NOTICE: If you completed a registered nurse program or the equivalent (2-4 year program) in a foreign country, you will only be eligible for a REGISTERED NURSE licensure. Foreign educated registered nurses are not eligible for practical nursing licensure in Indiana.
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 the 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 now being, or have you ever been treated for drug or alcohol abuse?

Yes Yes Yes

No No No

Yes Yes Yes Yes Yes

No No No No No

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)

APPLICANT Please attach two (2) passport-quality photograph taken not earlier than eight (8) weeks prior to the date of application, dated and signed across the back in the applicants handwriting, I certify that this is a true photograph of myself.

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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)

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