Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing (802) 828-2396 www.vtprofessionals.org INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE LICENSE BY EXAMINATION Applicant must submit the following: 1. Complete Vermont Application 2. Application Fee of $90.00 (n-refundable Processing Fee). Checks/Money orders are payable to Vermont Secretary of State. Credit/Debit cards are not accepted. 3. 2x2 Photo (Passport sized photo of head and shoulders taken within the last 6 months other than your driver s license or passport) 4. Verification of Education Form -This verification of education form must be completed and placed in a sealed envelope by the school. The school can either: A. Send the completed verification form, signed, dated, and affixed with the school stamp/seal along with a copy of official transcripts directly to the OR B. Give the completed verification form, signed, dated, and affixed with the school stamp/seal along with a copy of official transcripts to you so you may attach it unopened to your application. ***NOTE: Official transcripts are NOT required If the nursing program was completed in the State of Vermont. 5. Copy of Drivers License, government issued ID or passport 6. Register with Pearson VUE to take the NCLEX-RN exam NOTE: Any change of address or other contact information, by an applicant or licensee, must be forwarded to this office no later than thirty (30) days after change occurs. Send completed form to: 89 Main Street, 3 rd Floor Montpelier, VT 05620-3402 RN Examination Application 2015 0630
Vermont Secretary of State 89 Main Street, 3 rd Floor Montpelier VT 05620-3402 Licensing Board Specialist (802) 828-2396 www.vtprofessionals.org Registered Nurse Examination Application 2x2 Recent Photo- Paste Here Application Fee: $90.00 (non-refundable) Office Use Only Passport sized photo of head and shoulders taken within the last 6 months. (Use Ink or Typewritten only) First Name (Legal name; no nicknames) Middle Last Name Previous Name(s) (Maiden) Social Security Number: / / ** (Providing your social security number (SSN) is mandatory, and requested under the authority granted by 42 U.S.C. 405(c)(2)(C). It will be used by the Departments of Taxes, Child Support, and the Department of Labor in the administration of Vermont law, to identify individuals affected by such laws. Your SSN is not disclosed as part of a public records request); te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14). P.O. Box Mailing Address: Street/Apt # City/State/Zip Country Box Street/Apt # 911 Address: (if different than mailing) Suite/Department/Floor City/State/Zip Phone: ( ) - Cell Phone: ( ) - Work: E-Mail: Date of Birth Gender: (Circle One) Place of Birth (city, state, country) Female Male RN Examination Application 2015 0630 1
Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) 241-2319. OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) 828-2515 for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license. RN Examination Application 2015 0630 2
Section C: Vermont Mandatory Credential and Fitness Questions Circle or for each of these questions. If the answer is, follow the instructions provided. Have you committed acts of abuse, neglect, or misappropriation of patient property? If, provide a detailed written explanation and attach all related documents. Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Have you ever surrendered a license, certificate or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Have you EVER been convicted of a crime other than a minor traffic violation? (Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. ) If, you must provide a detailed written explanation and attach the official court documents (i.e., affidavit of probable cause, the information and/or the docket report.) Do you have any criminal charges pending against you in any jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. te: Vermont law requires that you report to the a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Are you currently participating in a supervised program or professional assistance program which monitors you in order to assure that you are not engaging in the use of alcohol or controlled substances? If, please provide the contract/stipulation under which you are practicing. RN Examination Application 2015 0630 3
Section D: Name of Nursing Program/School: Type of Program: Diploma Associate Degree Baccalaureate Degree Masters Degree Other Street or P.O. Box: City, State & Zip Code: Telephone Number: ( ) Name of Dean/Director: Section E: Required Enclosures The following must be submitted for licensure Verification of Education Form: This verification of education form must be completed and placed in a sealed envelope by the school. The school can either: A. Send the completed verification form, signed, dated, and affixed with the school stamp/seal along with a copy of official transcripts directly to the OR B. Give the completed verification form, signed, dated, and affixed with the school stamp/seal along with a copy of official transcripts to you so you may attach it unopened to your application. Verification of Education form: If you completed ANY of the subject areas listed through a school/program other than your primary nursing program you are responsible for requesting a verification of education form and a transcript from the additional school. NOTE: Official transcripts are NOT required If the nursing program was completed in the State of Vermont. A photocopy of your current driver s license, government issued ID or passport. Section F: Pearson Vue Registration You are encouraged to register with Pearson Vue Testing Agency prior to submitting this application. Until you are registered with Pearson Vue you will not be able to schedule your NCLEX. Pearson Vue NCLEX ID number: Section H: You may only apply for licensure by examination in one state. Have you applied for licensure by examination in any other US State or Territory? If yes, which state and on what date? If you have not taken the NCLEX examination within 6 months of receipt of this application the application will be destroyed along with all supporting documentation. If you are interested in reapplying, a new application and fee must be submitted. RN Examination Application 2015 0630 4
Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant Date Send completed form to: 89 Main Street, 3 rd Floor Montpelier, VT 05620-3402 RN Examination Application 2015 0630 5
Registered Nurse Verification of Education Form Directions: This verification of education form must be completed and placed in a sealed envelope by the school. The school can either: A. Send the completed verification form, signed, dated, and affixed with the school stamp/seal along with a copy of official transcripts directly to the OR B. Give the completed verification form, signed, dated, and affixed with the school stamp/seal along with a copy of official transcripts to you so you may attach it unopened to your application. NOTE: Official transcripts are NOT required If the nursing program was completed in the State of Vermont. If you have questions about completing this form, please call the Board office at 802-828-2396. Information Below To Be Completed by the Applicant Last Name First Name MI Former/Maiden Name (As on School Documents) Mailing Address Street City State Zip Date of Birth I hereby authorize the School of Nursing to furnish to the the information requested below. Signature Date Information Below To Be Completed by the School of Nursing Name of Nursing School Mailing Address Program Commenced (mm/dd/yyyy) Date of Program Completion(mm/dd/yyyy) Date of Graduation (mm/dd/yyyy) Degree/Certificate Earned Is your Nursing Program approved or accredited? YES NO Provide the name (s) of the governing body or agency below: Name RN Examination Application 2015 0630 6
Vermont Registered Nurse Verification of Education Form - Page 2 Last Name First Name MI Summary of Theoretical Education and Clinical Practice Hours This information must be listed in hours NOT credits. If it was an integrated nursing program you must break out the hours for each course listed below. Clinical Area of Practice Theory Hours Course/Subject Title/Number (REQUIRED) Clinical Hours Course/Subject Title/Number (REQUIRED) Adult Nursing Maternal/Infant Nursing Psychiatric/Mental Health Nursing Pediatric Nursing The following courses can not be combined through integrated coursework. Support Courses: Anatomy and Physiology Theory Hours Course/Subject Title/Number (REQUIRED) Microbiology Humanities Social/Behavioral Science Was the language of instruction and textbooks for the nursing program taught in English? YES NO Print Name Date Position/Title Telephone Email Signature of Dean/ Director Return to:, 89 Main St, 3 rd Floor, Montpelier, VT 05620-3402 Official School Seal/Stamp RN Examination Application 2015 0630 7