MULTISTATE LICENSE APPLICATION

Transcription

1 MULTISTATE LICENSE APPLICATION for LICENSED REGISTERED NURSE or LICENSED PRACTICAL/VOCATIONAL NURSE with an active Wyoming license This is a Legal Document. By completing and signing this document, you certify, under penalty of perjury and subject to the provisions of Wyoming Statute and its penalties, you have not knowingly submitted false or misleading information to the Wyoming State Board of Nursing (WSBN) on any application for licensure. INSTRUCTIONS AND GENERAL INFORMATION: (Keep a copy for your records) Thank you for applying to WSBN. The following instructions are guidelines for completing the application. Contact the Board office, , with any questions. We will be happy to assist you! This application is to be used for Registered Nurses or Licensed Practical/Vocational Nurses who: Currently hold a Wyoming license; Are residents of Wyoming as of January 19, 2018; and Have an active/unencumbered nursing license in Wyoming or any other state of licensure; Desire a multistate license issued by Wyoming as the home state. To be issued a multistate license, you must meet the enhanced Nurse Licensure Compact (enlc) Uniform Licensure Requirements (ULR) per W.S Article III (c)(i-ix), which includes a Criminal Background Check. ***Temporary permits are not available for a multistate license. You can continue to work in Wyoming on your current single state nursing license until your multistate license is issued, at which time your Wyoming single state license will be deactivated. Applicant must: Allow days for issuance of a multistate license. Complete the application. Type your information into the fillable PDF document and print the application; or print the application and complete neatly in INK. DO NOT LEAVE ANY BLANKS, if a section is not applicable add N/A to that line. Provide a copy of your social security card AND another form of lawful presence (driver s license, birth certificate, passport, or other items listed in application.) If a driver s license is used as proof of lawful presence, the license must have the same name as your social security card. Your application MUST also match the name on your social security card.

2 Provide all required information. Incomplete applications will: be held for one (1) year from the date received; and be destroyed after the one (1) year mark, requiring submission of a new application and fees. Provide a current mailing address, address and phone number to ensure prompt notification. Issuance of your license may be delayed if we do not have current contact information. Provide the following forms of payment: money order, cashier s check, VISA, MasterCard, or Discover. There are no refunds for an incomplete or withdrawn application. CRIMINAL BACKGROUND CHECK by Division of Criminal Investigation (DCI): In accordance with Wyoming Statute (c)(xxiv) and , you are required to complete a Criminal Background Check (CBC) before a multistate RN or LPN/LVN license can be issued. Fingerprints are used for the CBC. Obtain fingerprint cards at your local law enforcement agency. Fingerprints must be on two (2) "blue" FBI cards. Return these cards with your completed application and fees. Issuance of your multistate license is dependent upon receipt of CBC results from DCI. PLAN ACCORDINGLY! Procedures for obtaining a change, correction, or updating of an FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section [REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK]

3 FEES (All fees are non-refundable and subject to change) You must include payment (Cashier s Check, Money Order, VISA, MasterCard or Discover) with your application. WSBN CANNOT ACCEPT PERSONAL CHECKS OR CASH. Name of Applicant (PLEASE PRINT): If checked, enter cost in Amount Column Fee Amount Criminal Background Check/Fingerprint Cards (mandatory) $ $ RN or LPN/LVN multistate license processing fee (mandatory) $ $ Processing fee if paying by VISA, MasterCard or Discover (automatically assessed) $ 5.00 $ TOTAL amount due: $ Name, Address, and Phone Number of Individual Paying (PLEASE PRINT): Licensee Paying Third Party Paying Visa MasterCard Discover Card Number and Three Digit Security Code (on back of card): Security Code: Expiration Date: By signing below, I authorize the Board of Nursing to debit my credit card for the total amount indicated above. Signature: Date: Please help us to provide you with speedy customer service; review your application one more time to make sure you have submitted all the required documents and correct payment amount. Thank you for applying for multistate nursing licensure in Wyoming! We look forward to continuing our mission to serve and safeguard the people of Wyoming through the regulation of nursing education and practice.

4 Application for RN or LPN/LVN Multistate License 1) PERSONAL INFORMATION Social Security # Date of Birth Male/Female Last Name First Name Middle Name Maiden Name Mailing Address City State Zip Physical Address City State Zip (If Different from Above, Multi State License can t be issued with a P.O. Box) Home Phone Work Phone Cell Phone Address 2) LAWFUL PRESENCE Provide evidence of lawful presence in the U.S. to be granted professional licensure. Provide a COPY of your U.S. Social Security Card AND a COPY of one (1) of the following: U.S. Birth Certificate U.S. Passport (current) U.S. Certificate of Naturalization U.S. Certificate of Citizenship Permanent Resident Card (ie green card/visa I-551) (current) Driver s License (current) Other documentation that shows lawful admittance into the United States 3) NURSING EDUCATION PROGRAM (Completed for your initial RN or LPN/LVN) Name of Nursing Program City State: Date Enrolled Date Completed (month/year) (month/year) Degree Earned 4) NCLEX or RECOGNIZED PREDECESSOR EXAMINATION RESULTS Pass Fail [REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK]

5 5) LICENSURE List ALL states (including Wyoming) in which you are currently or have been licensed. Indicate license number and the name(s) in which license was issued. Attach a separate sheet if necessary. State License Type Legal Name in Which License was Issued Current Status (Active, Inactive, Expired) Original State of Licensure 6) VOLUNTEER OPTIONS (You are not required to complete this section) WYOMING MEDICAL REVIEW PANEL (Wyoming Residents with at least two (2) years nursing experience only): WYO. STAT through created the Medical Review Panel. All malpractice claims against a health care provider must be reviewed by the Medical Review Panel prior to the complaint being filed in any court. The Panel is composted of twelve (12) members. Members are selected by the Attorney General s Office from volunteers. YES, I would like to serve on this panel. NO, I do not wish to serve on this panel. WYOMING NURSE ALERT SYSTEM VOLUNTEER REGISTRATION If you would like to participate in a statewide system that will identify nurses willing to be mobilized to serve as volunteers during time of public health threats, infectious disease outbreaks, biological terrorism, and/or other disasters or emergencies in Wyoming, visit to enroll. [REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK]

6 7) HISTORY INFORMATION Applicant must: Answer every question Submit required documentation for any answer,application is INCOMPLETE until all required documentation is received. Examples Click Here 1. Has any disciplinary action been taken or is pending (i.e. open investigation) against you from a LICENSING AUTHORITY? a. No If YES, provide: Personal Statement Documentation of disciplinary action 2. In the last two (2) years or since your last renewal, have you been diagnosed with or treated for any physical or mental condition that significantly disrupts your motor function, cognition or behavior, and that may impair your ability to perform nursing services or duties competently; including but not limited to, bipolar disorder, schizophrenia or other major psychotic disorder? a. No If YES, provide: Personal Statement Progressreportfrom counselor/provider i. Discharge summary/aftercare plan from hospitalizations (IF you were hospitalized). 3. In the last two (2) years or since your last renewal, have you abused, excessively used, received any treatment for the use of: alcohol, prescription medication, or any other controlled or illicit substance having similar effects or have you tested positive for a controlled substance for which you did not have a valid prescription?" a. No If YES, provide: Personal Statement Progress report from counselor/provider i. Discharge summary/aftercare plan from hospitalizations (IF you were hospitalized). 4. Have you been terminated or permitted to resign in lieu of termination from a nursing or other health care position because of your use of alcohol or use of any controlled substance, habit-forming drug, prescription medication, or drugs having similar effects? a. No If, provide: Personal Statement Progress report from counselor/physician, discharge summary/aftercare plan from hospitalizations (IF you were hospitalized) 5. Have you EVER been arrested, convicted, pled guilty to, pled nolo contendere to (no contest), received a deferment, had a record expunged, or have charges pending against you for any crime including felonies, misdemeanors, municipal ordinances, and/or any military code of justice violations, including driving under the influence of any intoxicating substance? Do not include non-moving traffic violations or moving violations which did not involve alcohol or substance impairment. a. No If YES, provide a Personal Statement and Court Documents including: Information Sheet or Ticket Judgment and Sentencing Court Order Fines Paid Proof the case is closed Proof of compliance with the following (if applicable): Probation Complete/Expunged documents Classes Attended/Evaluation Completed and Subsequent Action on the Evaluation 6. Are you currently enrolled in an Alternative to Discipline program? a. No If, provide a personal statement with the start date, state where the program is located and program contact information. SIGNATURE REQUIRED: I certify under penalty of perjury and subject to the provisions of Wyo. Stat. Ann and its penalties, I am a Wyoming resident and I have not knowingly submitted false or misleading information to WSBN on any application for licensure. I understand WSBN reserves the right to verify any information in this application. Applicant s Signature: Date:

7 NONCRIMINAL JUSTICE APPLICANT S PRIVACY RIGHTS As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for a job or license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below. You must be provided written notification 1 that your fingerprints will be used to check the criminal history records of the FBI. If you have a criminal history record, the officials making a determination of your suitability for the job, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record. The officials must advise you that the procedures for obtaining a change, correction, or updating of your criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the job, license, or other benefit based on information in the criminal history record. 2 You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. 3 If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR through ) 1 Written notification includes electronic notification, but excludes oral notification. 2 See 28 CFR 50.12(b). 3 See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 42 U.S.C , Article IV(c); 28 CFR 20.21(c), 20.33(d) and 906.2(d).