Free 50026.FH11 - Indiana

APPLICATION FOR A LIMITED LICENSE TO PRACTICE NURSE-MIDWIFERY
State Form 50026 (R / 2-06) Approved by State Board of Accounts, 2006

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INSTRUCTIONS: Please type or print and answer all questions.

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 being requested by this state agency in accordance with I. C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

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

(

)

Name of School

SCHOOL OF NURSING Location

Dates Attended

Degree(s) Granted

Name of School

SCHOOL OF MIDWIFERY Location

Dates Attended

Degree(s) Granted

LIST ALL NAMES AND ADDRESSES OF EMPLOYERS AND RESPONSIBILITIES HELD OR PERFORMED SINCE GRADUATION FROM NURSING AND MIDWIFERY SCHOOLS

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LIST ALL STATES, INCLUDING INDIANA, IN WHICH YOU HAVE BEEN LICENSED, CERTIFIED, OR REGISTERED TO PRACTICE ANY REGULATED HEALTH OCCUPATION State Profession Number Issued Date Issued Status

Have you taken and passed the National Certification Examination given by the American College of Nurse-Midwives?

Yes
If Yes, list the date and location: Have you ever failed the National Certification Examination given by the American College of Nurse-Midwives?

No

Yes
If Yes, list the date and location:

No

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 this license 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, nurse midwife 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, or are formal charges pending: 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 Yes Yes No No No No No

Yes Yes Yes

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)

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AUTHORIZATION TO RELEASE 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 limited license to practice nurse-midwifery. 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 (You must place your signature on the front of your photograph.)

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