INSTRUCTIONS AND REQUIREMENTS ADVANCED PRACTICE REGISTERED NURSE (APRN) LICENSURE BY ENDORSEMENT

INSTRUCTIONS AND REQUIREMENTS ADVANCED PRACTICE REGISTERED NURSE (APRN) LICENSURE BY ENDORSEMENT Nurse Practitiner, Certified Nurse-Midwife, Certified Registered Nurse Anesthetist and Clinical Nurse Specialist Licensed in anther state r RN License inactive in SC - Seeking APRN License in SC Infrmatin fr Applicant Suth Carlina is a member f the Nurse Licensure Cmpact (NLC). The NLC des nt affect additinal requirements impsed by states fr advanced practice registered nursing. A multi-state licensure privilege t practice registered nursing granted by a party state must be recgnized by ther party states as a license t practice registered nursing if a license t practice registered nursing is required by state law as a precnditin fr qualifying fr advanced practice registered nurse authrizatin. A current APRN Suth Carlina license r temprary license is required t practice advanced nursing in this state. Orientatin is cnsidered the practice f nursing in Suth Carlina. Therefre, all nurses must pssess a current Suth Carlina license and/r temprary license befre beginning rientatin (including classrm instructin and reading plicies and prcedures). It is a vilatin f the Nurse Practice Act t begin rientatin withut the prper license and can result in actin by the Bard. Please visit ur website at www.llr.state.sc.us/pl/nursing t review the cmplete Suth Carlina Nurse Practice Act, Chapter 33, Sectin 40-33-34 fr mre details n educatinal and certificatin requirements. An applicant fr licensure as an Advanced Practice Registered Nurse (APRN) shall furnish evidence satisfactry t the bard that the applicant: (1) has met all qualificatins fr licensure as a registered nurse; and (2) hlds current specialty certificatin by a bard-apprved credentialing rganizatin. New graduates shall prvide evidence f certificatin within ne year f prgram cmpletin; hwever, psychiatric clinical nurse specialists shall prvide evidence f certificatin within tw years f prgram cmpletin; and (3) has earned a master's degree frm an accredited cllege r university, except fr thse applicants wh: (a) prvide dcumentatin as requested by the bard that the applicant was graduated frm an advanced, rganized (b) frmal educatin prgram apprpriate t the practice and acceptable t the bard befre December 31, 1994; r graduated befre December 31, 2003, frm an advanced, rganized frmal educatin prgram fr nurse anesthetists accredited by the natinal accrediting rganizatin f that specialty. CRNA's wh graduate after December 31, 2003, must graduate with a master's degree frm a frmal CRNA educatin prgram fr nurse anesthetists accredited by the natinal accreditatin rganizatin f the CRNA specialty. An advanced practice registered nurse must achieve and maintain natinal certificatin, as recgnized by the bard, in an advanced practice registered nursing specialty; (4) has paid the bard all applicable fees; and (5) has declared specialty area f nursing practice and the specialty title t be used must be the title which is granted by the bard-apprved credentialing rganizatin r the title f the specialty area f nursing practice in which the nurse has received advanced educatinal preparatin. Prescriptive Authrity: APRN s applying fr prescriptive authrity shall meet the requirements as nted in the S.C. Nurse Practice Act, Sectin 40-33- 34 (E). An applicant fr licensure as an Advanced Practice Registered Nurse whse license in anther state is currently restricted t prhibit the practice f nursing by any disciplinary actin (i.e. suspensin, revcatin, r ther actin) shall nt be cnsidered fr Suth Carlina license until the license frm the ther state f discipline is reinstated t permit the practice f nursing. Instructins & Infrmatin 1. Cmplete and submit the Applicatin fr Advanced Practice Registered Nurse License by Endrsement. Applicatin fees are nn-refundable. Mney rder, cashier s check r persnal check shuld be made payable t LLR-Bard f Nursing. Yur applicatin must include the fllwing: a) Recent 2 x 2 full faced passprt type pht, signed, dated and taped nt applicatin. b) Cpy f birth certificate r a valid passprt. (Cpy f hspital birth certificate is nt accepted). c) Cpy f scial security card, permanent resident card r a resident alien identificatin card assigned t a resident alien wh des nt have a scial security number. APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 1

d) Cpy f a current license frm anther state with the expiratin date. e) Have fficial transcript(s) sent directly frm master s f nursing educatinal prgram t Bard f Nursing. f) Submit cpy f current natinal advanced practice specialty certificatin (see web page fr apprved rganizatins). New graduates shall prvide evidence f certificatin within ne year f prgram cmpletin; hwever, psychiatric clinical nurse specialists shall prvide evidence f certificatin within tw years f prgram cmpletin. g) Cpies f legal dcuments that authrize a change in name (marriage license, divrce decree, curt rder). h) Cmplete Affidavit f Eligibility and submit secure and verifiable dcument. i) Obtain all SC physician signatures and license numbers t be included n yur applicatin, if applicable. j) Review the SC Nurse Practice Act and SC Medical Practice Act fr guidelines n the develpment f written prtcls. k) Applicants applying fr Prescriptive Authrity, cmplete and submit the fllwing: 1) Prescriptive Authrity applicatin; 2) Certificates f cmpletin fr 45 hurs f pharmactherapeutics f which 15 hurs must be in cntrlled substances (initial applicants); r 20 hurs f pharmactherapeutics f which 15 hurs must be in cntrlled substances (applicants licensed in anther state with prescriptive authrity). l) Applicatin fees - Mney rder, cashier s check r persnal check made payable t LLR-Bard f Nursing. $130.00 Permanent license nly. $140.00 Temprary license & permanent license. 2. Submit the verificatin frm t yur riginal state bard f RN licensure and Advanced Practice Licensure; r if yur riginal state f RN licensure is a member bard f NURSYS, prcess yur RN verificatin nline at https:\\www.nursys.cm and send the verificatin frm t yur riginal state f Advanced Practice Licensure. a. Mst bards f nursing charge a fee fr this service; therefre, yu must cntact the state nursing bard fr the amunt required. Verificatins must be submitted directly t the Suth Carlina Bard f Nursing. Be sure t send the verificatin frm alng with applicable fees t the riginal licensing bard as sn as pssible as this prcess may take several weeks t cmplete. If yur RN nursing educatin is nt included n yur verificatin, then yu are required t have an fficial transcript sent directly frm yur nursing educatin prgram t the SC Bard f Nursing ffice. 3. Temprary License-Temprary licenses are nt available t applicants with prir criminal cnvictin(s), pending criminal charge(s), current bard f nursing disciplinary sanctin(s) r pending bard actin(s). A persnal written letter f explanatin utlining the details f all affirmative answers must be prvided with yur applicatin. 4. Name Used n License - All licenses are issued in the applicant s legal name. The name as it appears n yur birth certificate will be printed n yur license, unless it has been changed legally by marriage, divrce r ther legal actin. If yur name changes (marriage, divrce r ther curt rder) after the applicatin has been filed, a cpy f the legal dcument changing yur name must be submitted t this ffice s that the crrect name appears n the license. Yur first name cannt be drpped and yur middle name used n the license unless yu have legally made this change and have prvided dcumentatin (curt dcuments). 5. Ntificatin f Initial Emplyment r Change f Practice Sectin 40-33-34 (D)(3) and (H)(4) f the S.C. Nurse Practice Act requires that individuals wh change r discntinue practice settings r physician (r dentist) shall ntify the Bard f such change within 15 business days and prvide verificatin f apprved written prtcls (guidelines). Failure t ntify the Bard f a practice change shall be cnsidered miscnduct and subjects the licensee t disciplinary actin. Cmplete the enclsed ntificatin frm and return t the Bard f Nursing within the designated time as described in the Statue. The ntificatin frm can be cpied as needed. 6. License Renewal - Suth Carlina Nursing Licenses are renewed every even year. All licenses must be renewed by April 30th every even year. It is the licensee s respnsibility t renew their license. D nt wait until renewal time t ntify the Bard f a change in yur address, supervisry r practice setting. See 40-33-40 f the Nurse Practice Act t review the cmpetency requirements and 40-33-34(E) (3) fr prescriptive authrity renewal requirements. APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 2

Suth Carlina Department f Labr, Licensing and Regulatin Suth Carlina Bard f Nursing 110 Centerview Dr. Clumbia SC 29210 P.O. Bx 12367 Clumbia SC 29211-2367 Phne: 803-896-4550 NURSEBOARD@llr.sc.gv Fax: 803-896-4515 www.llr.sc.gv/pol/nursing/ Criminal Backgrund Check (CBC) Effective March 2, 2009, an applicant fr a license t practice nursing in Suth Carlina shall be subject t a criminal histry backgrund check as defined in 40-33-25 f the Nursing Practice Act. This prcess requires yu t furnish a full set f fingerprints and additinal infrmatin required t enable a criminal histry backgrund check t be cnducted by the State Law Enfrcement Divisin (SLED) and the Federal Bureau f Investigatin (FBI). These services are prvided by IdentGO Centers and are perated by MrphTrust USA. Residents f Suth Carlina shuld g nline t schedule fr fingerprinting services: http://www.identg.cm/fp/suthcarlina.aspx r call (866) 254-2366 fr assistance in scheduling. Scheduling services will prvide detailed infrmatin f frms f identificatin that will be required. If yu are a nn-resident f Suth Carlina and d nt reside in an area near Suth Carlina, please fllw the Nn- Resident Card Scan Prcessing Prcedures belw. Nn-Resident Card Scan Prcessing Prcedures Fr applicants that reside ut f Suth Carlina wh wish t use the IdentGO/Mrph Trust USA Centers, yu may use these centers that are lcated in Suth Carlina nly. If an applicant des nt reside near Suth Carlina, they must cmplete and submit the fingerprint cards by fllwing the directins belw. This prgram utilizes advanced scanning technlgy t cnvert a traditinal fingerprint card (hard card) int an electrnic fingerprint recrd. The sectin belw details the prcedures fr submitting fingerprints t the MrphTrust card scan department. Applicant shuld cntact IdentGO/MrphTrust (866-254-2366) t verify the current fee t submit. Applicants shuld btain a set f fingerprints frm a lcal law enfrcement agency r ther entity that prvides fingerprinting services. These fingerprint cards may be either traditinal ink rlled fingerprints r electrnically captured and printed fingerprint cards. Fingerprints may be submitted n FBI applicant cards. The applicant may call r email the Nursing Bard t have the FBI applicant cards mailed t them. Phne: 803-896-4550 r email: nursebard@llr.sc.gv. Due t agency specific infrmatin, MrphTrust USA des nt prvide fingerprint cards t applicants. Applicant shuld ensure the fingerprint cards are cmpletely filled ut. Required infrmatin includes: ORI Number: SC920112Z Full Name Hme Address Place f Birth (State r Cuntry Only) Citizenship Scial Security Number Date f Birth Sex, Height, Weight, Hair Clr and Eye Clr Reasn fingerprinted Mail the fully cmpleted card and applicable fee (Include full name f applicant n the check) t: Identg Cardscan Department SC Cardscan Prcessing 6840 Carthers Parkway STE 650 Franklin, TN 37067-9929 Fllw-up calls and questins n the prcessing f a fingerprint card shuld be made directly t IdentGO/MrphTrust at (866) 254-2366 and speak t a custmer service representative. DO T return fingerprint card r fingerprint prcessing fee in with yur applicatin r t the Bard f Nursing. This will delay the prcessing f yur applicatin.

NCRIMINAL JUSTICE APPLICANT S PRIVACY RIGHTS As an applicant wh is the subject f a natinal fingerprint-based criminal histry recrd check fr a nncriminal justice purpse (such as an applicatin fr a jb r license, an immigratin r naturalizatin matter, security clearance, r adptin), yu have certain rights which are discussed belw. Yu must be prvided written ntificatin 1 that yur fingerprints will be used t check the criminal histry recrds f the FBI. If yu have a criminal histry recrd, the fficials making a determinatin f yur suitability fr the jb, license, r ther benefit must prvide yu the pprtunity t cmplete r challenge the accuracy f the infrmatin in the recrd. The fficials must advise yu that the prcedures fr btaining a change, crrectin, r updating f yur criminal histry recrd are set frth at Title 28, Cde f Federal Regulatins (CFR), Sectin 16.34. If yu have a criminal histry recrd, yu shuld be affrded a reasnable amunt f time t crrect r cmplete the recrd (r decline t d s) befre the fficials deny yu the jb, license, r ther benefit based n infrmatin in the criminal histry recrd. 2 Yu have the right t expect that fficials receiving the results f the criminal histry recrd check will use it nly fr authrized purpses and will nt retain r disseminate it in vilatin f federal statute, regulatin r executive rder, r rule, prcedure r standard established by the Natinal Crime Preventin and Privacy Cmpact Cuncil. 3 If agency plicy permits, the fficials may prvide yu with a cpy f yur FBI criminal histry recrd fr review and pssible challenge. If agency plicy des nt permit it t prvide yu a cpy f the recrd, yu may btain a cpy f the recrd by submitting fingerprints and a fee t the FBI. Infrmatin regarding this prcess may be btained at http://www.fbi.gv/abut-us/cjis/backgrund-checks. If yu decide t challenge the accuracy r cmpleteness f yur FBI criminal histry recrd, yu shuld send yur challenge t the agency that cntributed the questined infrmatin t the FBI. Alternatively, yu may send yur challenge directly t the FBI. The FBI will then frward yur challenge t the agency that cntributed the questined infrmatin and request the agency t verify r crrect the challenged entry. Upn receipt f an fficial cmmunicatin frm that agency, the FBI will make any necessary changes/crrectins t yur recrd in accrdance with the infrmatin supplied by that agency. (See 28 CFR 16.30 thrugh 16.34.) 1 Written ntificatin includes electrnic ntificatin, but excludes ral ntificatin. 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. 14616, Article IV(c); 28 CFR 20.21(c), 20.33(d) and 906.2(d).

APPLICATION FOR ADVANCE PRACTICE REGISTERED NURSE (APRN) LICENSURE BY ENDORSEMENT Cmplete all sectins f this applicatin by prviding all f the requested infrmatin. Please print. Answer all questins and submit with prper fee. Careful cmpletin f this applicatin will avid a delay in prcessing. Yu must ntify the Bard in writing within fifteen (15) business days f any address changes after yu file this applicatin in rder t receive infrmatin frm the Bard. This applicatin frm is a public dcument btainable under the Freedm f Infrmatin Act. Persnal infrmatin prvided in this applicatin may be subject t public scrutiny r release under the SC Freedm f Infrmatin Act r ther prvisins f federal and state law. The Scial Security Number (SSN) is nt subject t disclsure as public infrmatin. The disclsure f the SSN fr identificatin purpses is authrized and mandated by federal statutes requiring state bard t reprt t the Natinal Practitiner Data Bank (NPDB), amng ther things. The Suth Carlina Law requires that every individual wh applies fr an ccupatinal r prfessinal license prvide a scial security number fr use in the establishment, enfrcement and cllectin f child supprt bligatins and fr reprting t certain databanks established by law. Failure t prvide yur scial security number fr these mandatry purpses will result in the denial f yur licensure applicatin. Scial security numbers may als be disclsed t ther gvernmental regulatry agencies and fr identificatin purpses t testing prviders and rganizatins invlved in prfessinal regulatin. Yur scial security number will nt be released fr any ther purpse nt prvided fr by law. If yu were previusly licensed by the Suth Carlina Bard f Nursing as an APRN, d nt cmplete this applicatin frm. Visit the Bard f Nursing Website at www.llr.state.sc.us/pl/nursing fr APRN Reactivatin/Reinstatement applicatin t reinstate yur APRN license. Applying as: Nurse Practitiner Certified Nurse-Midwife Certified Registered Nurse Anesthetist Clinical Nurse Specialist (CNS) PART I: Applicant Identifying Infrmatin 1. Last Name 2. First Name 3. Middle Name 4. Suffix (Jr., III) 5. Title Mr. Mrs. Ms. Dr. 6. Maiden Name 7. Scial Security Number 8. Mailing Address (Street r PO Bx, City, State, Zip) 9. Hme Address (Street, City, State, Zip nt PO Bx) 9a. Cunty 9b. Hme Phne 9c. Hme Fax 9d. Hme Email 10. Identify Preferred Mailing address. Mailing Hme 11. Place f Birth (City, State & Cuntry) 12. Date f Birth MM/DD/YYYY 13. Gender Male Female 14. Race (Fr Statistical Purpses Only) African American/Black American Indian Asian/Oriental Hispanic/Spanish Origin Caucasian/White Other 15 Have yu ever been licensed in Suth Carlina? If yes, SC Registered Nurse (RN) License Number 16. Declaratin f Primary State f Residence: (where I hld a driver s license, pay taxes r vte) I declare my primary state f residence is I plan t primarily practice in the state f. I am in the military r federal gvernment. I am currently licensed in (state) and I d nt intend t wrk utside f military r federal gvernment. APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 4

PART II: Educatin/Prfessinal Educatin List in chrnlgical rder frm date f graduatin t the present all prfessinal educatin. D nt include cntinuing educatin cursewrk r clinical training. SCHOOL /INSTITUTION NAME LOCATION (City, State & Cuntry) DATES OF ATTENDANCE DID YOU COMPLETE PROGRAM HIGHEST GRADE COMPLETED OR DEGREE EARNED FROM (Mnth/Year) TO (Mnth/Year) Y N Y N Y N Transcripts: Prvide an fficial transcript sent directly t the bard frm yur master s nursing educatin prgram. The applicatin cannt be cmpletely prcessed until we have the fficial transcript shwing cmpletin f a masters in nursing pst masters r dctrate Cllege r University Accredited? Yes N Graduate Nursing Prgram Accredited? Yes N If yes, Accredited by: Y N PART III: Recrd f Examinatin(s) Cmplete the requested infrmatin belw if licensure examinatin was taken in this state r any ther state. List each examinatin attempt belw. Attach additinal sheets if necessary. Failure t disclse an examinatin attempt may result in the denial f yur applicatin r ther apprpriate actin. Name f Examinatin State r Cuntry Date f Examinatin Passed/Failed/Scre (If scre, enter scre) Specialty Certificatin Exam(s) Certifying Organizatin(s) Original Date f Certificatin Expiratin Date f Certificatin PART IV: Recrd f Licensure Cmplete the requested infrmatin belw if yu have ever been licensed, certified r registered t practice in any prfessin r ccupatin. Yu must identify the methd by which yu btained yur license(s) and include jurisdictin bth within and utside the United States, current r inactive. Failure t disclse all licenses held may result in denial f yur applicatin r ther apprpriate actin. (Attach additinal sheets if necessary.) Jurisdictin Credential Type (LPN, RN r APRN) License Number/Name n License Hw License Obtained (Type f Exam r Endrsement) Date Issued State f Original (Initial) Licensure: List Other Jurisdictins f Licensure: APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 5

PART V: Emplyment Histry List all related emplyment chrnlgically, mst recent first, fr the past five (5) years. If yu have never been emplyed in the prfessin yu are applying fr, insert N/A fr Nt Applicable. Phtcpy this page and attach if additinal space is required. 1. Emplyer Name Emplyer Address (Street, City, State, Zip) Jb Title Type f Emplyment Dates f Emplyment Full-time Part-time Frm: T: Abbreviated Descriptin f Duties Perfrmed Hurs Wrked per Week Reasn fr Leaving 2. Emplyer Name Emplyer Address (Street, City, State, Zip) Jb Title Type f Emplyment Dates f Emplyment Full-time Part-time Frm: T: Abbreviated Descriptin f Duties Perfrmed Hurs Wrked per Week Reasn fr Leaving 3. Emplyer Name Emplyer Address (Street, City, State, Zip) Jb Title Type f Emplyment Dates f Emplyment Full-time Part-time Frm: T: Abbreviated Descriptin f Duties Perfrmed Hurs Wrked per Week Reasn fr Leaving 4. Emplyer Name Emplyer Address (Street, City, State, Zip) Jb Title Type f Emplyment Dates f Emplyment Full-time Part-time Frm: T: Abbreviated Descriptin f Duties Perfrmed Hurs Wrked per Week Reasn fr leaving 5. Emplyer Name Emplyer Address (Street, City, State, Zip) Jb Title Type f Emplyment Dates f Emplyment Full-time Part-time Frm: T: Abbreviated Descriptin f Duties Perfrmed Hurs Wrked per Week Reasn fr Leaving APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 6

PART VI: Persnal Histry Infrmatin If yu answer yes t any f the questins belw (1-10), yu must attach a full written explanatin pertaining t that particular questin. 1. Have yu ever had any applicatin fr any prfessinal license, certificatin, r registratin refused r denied by any licensing authrity? 2. Have yu ever been refused r denied the privilege f taking an examinatin required fr any prfessinal license? 3. Have yu ever been the subject f disciplinary actin with regard t a license, been revked r sanctined by any licensing authrity, assciatin, licensed facility, r staff f such facility? 4. Have yur privileges ever been restricted r terminated by any assciatin, licensed facility, r staff f such facility; r have yu ever vluntarily r invluntarily resigned r withdrawn frm such assciatin r facility t avid impsitin f such measures? 5. T yur knwledge have any unreslved r pending cmplaints ever been filed against yu with any federal r state agency, prfessinal assciatin, licensed hspital r clinic, r staff f such hspital r clinic? 6. Have yu ever been arrested, charged r cnvicted (including a nl cntender plea r guilty plea) in any state r federal curt (ther than minr traffic vilatins) whether r nt sentence was impsed r suspended? If yes, attach a certified cpy f the curt recrds regarding yur cnvictin, the nature f the ffense, date f discharge, if applicable, as well as a statement frm the prbatin r parle fficer sent directly t the Bard frm the abve-mentined authrities. 7. Currently are yu being treated r within the last five years, have yu been treated fr drug r alchl addictin that might interfere with yur ability t cmpetently and safely perfrm the essential functins f practice? 8. Currently r within the last five years, have yu been treated fr any physical, mental r emtinal cnditin that might interfere with yur ability t cmpetently and safely perfrm the essential functins f practice? 9. Currently r within the last five years, have yu develped any disease r cnditins, physical, mental, r emtinal that might interfere with yur ability t cmpetently and safely perfrm the essential functins f practice? 10. a. Have yu ever vluntarily surrendered a nursing license? b. Have yu ever vluntarily surrendered a cntrlled substance r DEA registratin? 11. a. D yu plan t prescribe Schedules III thrugh V? b. D yu have a cntrlled substance r DEA registratin? NA NA NA PART VII: Specialty Area(s) & Certificatin(s) 1. Specialty area f APRN practice. 2. Describe yur specialty area in advanced nursing practice. (This sectin will be assessed by an Advanced Practice Nursing Cnsultant wh will determine the clsest scpe f practice area in accrdance with Natinal Certificatin) 3. D yu hld current specialty certificatin by a natinal credentialing rganizatin(s)? Certifying Organizatin Expiratin date (Attached a cpy f certificate) Check here if yu are trained and willing t vlunteer yur services during a biterrrism disaster? Check here if yu are trained and willing t vlunteer yur services during a disaster? Other APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 7

PRIMARY Practice Site (If mre than 2 sites, duplicate frm as needed) PART VIII: Advanced Practice Emplyment (Current) Emplyer Name (Use blank cpies f this frm t add multiple practice sites and/r physicians): Practice Address: (Street, City, State, Zip Cde) Supervising Physician: Primary Physician Alternate Supervising Physician Supervising Physician (All physicians must have a permanent SC license in gd standing) Business Address: (Street, City, State, Zip) Prximity t NP, CNM, CNS in Miles: SC Physician s License N: Practice Specialty: Primary Practice Site Phne Number Signature f Supervising Physician Date By signing this dcument, I affirm that I will nt supervise any mre than three NPs, CNMs r CNSs at any given time withut prir apprval by the SC Bard f Nursing and SC Bard f Medical Examiners, pursuant t S.C. Cde Ann. 40-33-34(C), 40-47-20(43) and 40-47-195(C). SECONDARY/ADDITIONAL Practice Site (If mre than 2 sites, duplicate frm as needed) Emplyer Name: Practice Address: (Street, City, State, Zip) Supervising Physician: Primary Physician Alternate Supervising Physician Supervising Physician (All physicians must have a permanent SC license in gd standing) Business Address: (Street, City, State, Zip) Prximity t NP, CNM, CNS in Miles: SC Physician s License N: Practice Specialty: Secndary Practice Site Phne Number Signature f Supervising Physician Date By signing this dcument, I affirm that I will nt supervise any mre than three NPs, CNMs r CNSs at any given time withut prir apprval by the SC Bard f Nursing and SC Bard f Medical Examiners, pursuant t S.C. Cde Ann. 40-33-34(C), 40-47-20(43) and 40-47-195(C). A cpy f practice prtcls, fr NP, CNM, r CNS/ cpy f written apprved guidelines fr CRNA signed and dated by all the physicians listed abve and myself are n file in the ffice/agency f my emplyment and available upn request. APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 8

PART IX: Certifying Statement I, (print name), am the persn described and identified, f gd mral character, and the persn named in all dcuments presented in supprt f this applicatin. I have carefully read the questins in the freging applicatin and have answered them cmpletely, withut reservatins f any kind, and I declare that all statements made by me herein are true and crrect. Shuld I furnish any false r incmplete infrmatin in this applicatin, I hereby agree that such act shall cnstitute the cause fr denial r revcatin f my license t practice nursing in Suth Carlina. I hereby authrize the Suth Carlina Bard f Nursing t utilize my Scial Security Number (SSN) in making necessary reprts t the Natinal Cuncil f State Bards f Nursing (NCSBN) data center fr cmpilatin f infrmatin abut applicants and licenses in rder t crdinate licensure and disciplinary activities between the individual states licensing bards, and t federal and state entities, as required by law. Applicant s Signature (D nt print) Date Tape pht at tp nly Subscribed and swrn t befre me this day f, 20. Signature f Ntary Public Attach recent passprt pht here 2 x 2 N cpies Sign and date frnt f pht D nt staple My Cmmissin Expires: DID YOU REMEMBER TO: Cmplete and answer all questins in ink. Sign, date, and have applicatin ntarized. Cmplete the Affidavit f Eligibility. (Next 2 pages) Sign, date yur pht n frnt and tape nt yur applicatin. Black & white phts are acceptable. Submit a cpy f yur birth certificate r a valid passprt. (Cpy f hspital birth certificate nt accepted) Submit a cpy f yur current nursing licenses frm ther states with the expiratin date (RN and APRN). Submit a cpy f yur scial security card, permanent resident card r a resident alien identificatin card. Submit a cpy f yur marriage license; divrce decree r curt dcument as prf f legal change in name. These dcuments are part f yur file and are nt returned. Register with NURSYS if yur riginal state f RN licensure is a member bard f NURSYS r submit the Verificatin Frm t the bard where yu tk the NCLEX and received yur riginal license if the bard is nt a member f Nursys. Als, submit the Verificatin Frm t yur riginal state f advanced practice licensure prescriptive authrity must be verified (if applicable). Have fficial transcript sent directly frm yur master s f nursing educatinal prgram t the SC Bard f Nursing. Submit a cpy f a current advanced practice nursing specialty certificatin. (New graduates shall prvide evidence f certificatin within ne year f prgram cmpletin; hwever, psychiatric clinical nurse specialists shall prvide evidence f certificatin within tw years f prgram cmpletin). Review the SC Nurse Practice Act and Medical Practice Act fr guidelines n the develpment f written prtcls. Obtain all SC physician signatures and license numbers t be included n yur applicatin, if applicable. Submit 45 hurs f pharmactherapeutics f which 15 hurs must be in cntrlled substances (initial applicants) r 20 hurs f pharmactherapeutics f which 15 hurs must be in cntrlled substances (applicants licensed in anther state with prescriptive authrity). Signatures f SC supervising physicians are necessary befre prescriptive authrity is added t yur license. Apprved cntrlled substance curses can be fund at http://academicdepartments.musc.edu/chp/pa/cme/pac.htm and http://ahecu.mrms3.net/. Enclse a nn-refundable fee - Mney rder, cashier s check r persnal check made payable t LLR-Bard f Nursing. $130.00 Permanent license nly. $140.00 Temprary license & permanent license. Cmplete the criminal backgrund check requirements. If yu need a fingerprint card, please e-mail NurseBard@LLR.SC.GOV. Check the status f yur applicatin nline at www.llr.state.sc.us/pl/nursing. Once all requirements have been received, a license number may be generated within 10 business days. During peak times, the applicatin review/apprval prcess may take lnger. APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 9

STATE OF SOUTH CAROLINA DEPARTMENT OF LABOR, LICENSING AND REGULATION VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES AFFIDAVIT OF ELIGIBILITY Pursuant t Sectin 8-29-10, et seq. f the Suth Carlina Cde f Laws (1976, as amended), the Department f Labr, Licensing and Regulatin must verify that any persn wh applies fr a Suth Carlina license is lawfully present in the United States. Cmplete and sign this affidavit f eligibility. The infrmatin prvided is subject t verificatin. Sectin A: LAWFUL PRESENCE in the United States. The undersigned, f (Print clearly First, Middle, and Last name) (Hme Address, City, State, and Zip Cde) Check nly ne bx: 1. I am a United States citizen; r 2. I am a Legal Permanent Resident f the United States eighteen years f age r lder; r 3. I am a Qualified Alien r nn-immigrant under the Federal Immigratin and Natinality Act, Public Law 82-414, eighteen years f age r lder, and lawfully present in the United States. 4. Other: Please submit any dcumentatin that supprts this status. Date f Birth: Alien Number: I-94 Number: (If yu checked number 2, 3, r 4 yu must attach a cpy f yur immigratin dcuments. See Instructin sheet fr a list f accepted immigratin dcuments.) being first duly swrn depses and states as fllws: Sectin B: ATTESTATION. I understand that in accrdance with sectin 8-29-10 f the Suth Carlina Cde f Laws, a persn wh knwingly and willfully makes a false, fictitius, r fraudulent statement r representatin in an affidavit shall, in additin t ther sanctins impsed by this State r the United States, be guilty f a felny, and upn cnvictin must be fined and/r imprisned fr nt mre than 5 years (r bth). I understand that the representatins made in this Affidavit shall apply thrugh any license(s) r renewals issued, and that I shall have an affirmative duty t immediately advise the Department f Labr, Licensing and Regulatin f any change f my immigratin r citizenship status. I swear and attest the infrmatin cntained herein is true and crrect t the best f my knwledge. I understand that under Suth Carlina law, prviding false infrmatin is grunds fr denial, suspensin, r revcatin f a license, certificate, registratin r permit. Signature f Affiant SWORN t befre me this day f Ntary Public fr My Cmmissin Expires: APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 10

I INSTRUCTION SHEET FOR COMPLETING AFFIDAVIT OF ELIGIBILITY CHECK bx 1: If yu are a United States Citizen by birth r naturalizatin CHECK bx 2: If yu are a Legal Permanent Resident and yu are nt a U.S. Citizen, but are residing in the U.S. under legally recgnized and lawfully recrded permanent residence as an immigrant. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. CHECK bx 3: If yu are a Qualified Alien. Yu are a Qualified Alien if yu are: An alien wh is lawfully admitted fr residence under the INA. An alien wh is granted asylum under Sectin 208 f the INA. A refugee wh is admitted t the United States under Sectin 207 f the INA. An alien wh is parled int the United States under Sectin 212(d)(5) f the INA fr a perid f at least 1 year. An alien whse deprtatin is being withheld under Sectin 243(h) f the INA (as in effect prir t April 1, 1997) r whse remval has been withheld under Sectin 241(b)(3). An alien wh is granted cnditinal entry pursuant t Sectin 203(a)(7) f the INA as in effect prir t April 1, 1980. An alien wh is a Cuban/Haitian Entrant as defined by Sectin 501(e) f the Refugee Educatin Assistance Act f 1980. An alien wh has been battered r subjected t extreme cruelty, r whse child r parent has been battered r subject t extreme cruelty. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. ACCEPTED IMMIGRATION DOCUMENTS: Unexpired Reentry Permit (I-327) Permanent Resident Card r Alien Registratin Receipt Card With Phtgraph (I-551) Unexpired Refugee Travel Dcument (I-571) Unexpired Emplyment Authrizatin Card Which Cntains a Phtgraph (I-688) Machine Readable Immigrant Visa (with Temprary I-551 Language) Temprary I-551 Stamp (n passprt r I-94) I-94 (Arrival/Departure Recrd) in Unexpired Freign Passprt I-20 (Certificate f Eligibility fr Nnimmigrant, F-1, Student Status) DS2019 (Certificate f Eligibility fr Exchange Visitr, J-1, Status) APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 11

NURSYS ONLINE VERIFICATION INSTRUCTIONS 1. If yur riginal state f RN licensure is T ne f the states listed belw, DO T attempt t verify yur license at https:\\www.nursys.cm. Instead, fllw the verificatin instructins n the Suth Carlina Bard f Nursing verificatin frm. Alaska Arkansas American Sama Arizna Clrad District f Clumbia Delaware Flrida Guam Iwa Idah Indiana Kentucky Luisiana-RN Massachusetts Maryland Maine Michigan Minnesta Missuri Nrthern Mariana Islands Mississippi Mntana Nrth Carlina Nebraska New Hampshire New Jersey New Mexic Nevada New Yrk Ohi Oregn Rhde Island Suth Dakta Tennessee Texas Utah Virginia Virgin Islands Vermnt Washingtn Wiscnsin West Virginia-PN Wyming NURSYS Secure Online Verificatin Prcess: https:\\www.nursys.cm APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 12

Suth Carlina Bard f Nursing Verificatin Frm Use this frm ONLY if yur riginal state f RN licensure is T listed n the preceding page (Nursys page). Use this frm t verify yur riginal state f advanced practice licensure (make cpies as necessary). Mst states charge a fee t cmplete this frm. Check with each state bard befre mailing this frm. PART I: T be cmpleted by the applicant and frwarded t the riginal state f licensure with applicable fee. Name First Middle Maiden Last Previus Names(s) Current Street Address City State Zip Date f Birth (mm/dd/yyyy) Scial Security # Nursing Educatin Prgram Nam as n riginal license Degree Granted First Middle Maiden Last City f Prgram State Date f Cmpletin Original State f Licensure Issue Date f Original License Original License Number Type f License: APRN RN Current State f Licensure Issue Date f Current License Current License Number Type f License APRN RN LIST ALL OTHER STATES OF LICENSURE State: License Number: Date Issued: State: License Number: Date Issued: State: License Number: Date Issued: I hereby authrize all identified Bards f Nursing t release my licensure data t the Suth Carlina Bard f Nursing. Signature Date PART II: T be cmpleted by the riginal state f licensure and frwarded t: Suth Carlina Bard f Nursing, P. O. Bx 12367, Clumbia, SC 29211 This is t certify that was issued license number Date Issued (Applicant Name) t practice as a(n) APRN RN Prescriptive authrity Issued: Are prescriptive rights still active? Yes N Licensed by: Examinatin Endrsement Waiver/Equivalency Current Licensure Status: Active Inactive Lapsed Expiratin Date: Has this license ever been encumbered (denied, revked, suspended, limited, placed n prbatin)? Yes N Disciplinary Actin Pending? Explain yes respnses and/r attach a certified cpy f the actin. Yes N Nursing Educatin Prgram Cmpleted Apprved by State? Yes N Lcatin (city/state) Graduatin Date Type f Nursing Prgram DIP ADN BSN Master s Other STATE BOARD TEST POOL EXAMINATION RN LP/VN NCLEX RN LP/VN Scres : Medical Nursing Psychiatric Nursing Obstetric Nursing Surgical Nursing Nursing f Children _ Series/Frm Number f times applicant tk exam Exam Dates: Signature Title State Date APRN Endrsement Applicatin (Rev 03/2015) Bard Website www.llr.state.sc.us/pl/nursing/- Page 13