Free 50024.FH11 - Indiana

APPLICATION FOR LICENSURE BY EXAMINATION FOR GRADUATES OF U.S. NURSING SCHOOLS
State Form 50024 (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/

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

Issuance date (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

Licensed Practical Nurse

Yes, repeat applicant

No, first time taking the examination

If Yes, list the date(s) and state where taken:

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 other last names you have used State Place of birth (city and state) ZIP code

(

)

Social Security number *

NURSING EDUCATION * DO NOT USE THIS APPLICATION IF YOU GRADUATED FROM A NURSING PROGRAM OUTSIDE OF THE UNITED STATES. A FOREIGN GRADUATE EXAMINATION APPLICATION CAN BE DOWNLOADED AT www.pla.IN.gov .

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? (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 nursing and/or any other 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 nursing and/or any other regulated health occupation. LICENSE TYPE STATE / COUNTRY / TERRITORY NUMBER DATE OF ISSUE STATUS

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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 No No Yes Yes Yes No No No

Yes Yes Yes

No No No

REPEAT APPLICANTS ONLY: If your answer was Yes to any of the above questions, and your detailed statement was submitted to the State of Indiana with your original application and has not changed, please initial here: ____________ You only need to submit additional information if circumstances have changed since you last submitted a detailed statement regarding the above questions. 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)

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, the program directors signature and the school seal on the front of your photograph.)

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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/

CERTIFICATE OF COMPLETION
RN LPN

I hereby certify that______________________________________________________ was admitted to the ________________________________________________________________ Program of Nursing located in ______________________________ on _________________________ and completed requirements for graduation on ____________________________________________ will/did graduate on ________________________________ . His/Her Social Security number is ________________________________ .

There is evidence in our permanent records that this person has met the requirements as specified in Indiana law.

DATE:__________________________ SIGNED _______________________________________
Signature

SCHOOL SEAL

Printed Name

Dean / Director / Designee

APPLICANT: The CERTIFICATE OF COMPLETION form must be completed and sent to the Professional Licensing Agency by your program of nursing. You will not be declared eligible to take the examination until this form is received by the Agency. DIRECTOR OF PROGRAM: The applicant cannot be declared eligible to take the examination until this form is received by the Professional Licensing Agency. CERTIFICATES OF COMPLETION SHOULD NOT BE SENT TO THE PROFESSIONAL LICENSING AGENCY UNTIL THE APPLICANT HAS COMPLETED THE PROGRAM OF NURSING.

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