INSTRUCTIONS AND REQUIREMENTS FOR ADVANCED PRACTICE REGISTERED NURSE (APRN)

Infrmatin fr Applicant INSTRUCTIONS AND REQUIREMENTS FOR ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Updating frm a current Suth Carlina RN License t SC APRN License) 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, Sectin 40-33-34 fr mre details n educatinal and certificatin requirements. Prir t cmpleting applicatin, review Sectin 40-33-34 f the Nurse Practice Act fr statutry requirements fr licensure as an Advanced Practice Registered Nurse (APRN) in Suth Carlina. The Nurse Practice Act can be fund under Laws/Plicies n ur website www.llr.state.sc.us/pl/nursing/ If yu were previusly licensed by the SC Bard f Nursing as an APRN, d nt cmplete this applicatin frm. G t www.llr.state.sc.us/pl/nursing fr the APRN Reactivatin/Reinstatement applicatin. Sectin 40-33-34(A) 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 frmal educatin prgram apprpriate t the practice and acceptable t the bard befre December 31, 1994; r (b) 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. ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 10/12) 1 f 12

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). Instructins & Infrmatin 1. Cmplete and submit this applicatin t the Bard if yu have a current SC RN license and want t update yur RN license credential t a SC Advanced Practice Registered Nurse (APRN) license. 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: 1. Recent 2 x 2 full faced passprt type pht, sign and date n frnt r back and tape alng tp edge nly nt yur applicatin. 2. Cpy f current SC RN license with the expiratin date. 3. Dcument f earned master s degree ( 40-33-34) Have fficial transcripts sent directly frm yur master s frm nursing educatinal prgram t Bard f Nursing. 4. Cpy f 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). 5. Cpies f legal dcuments that authrize a change in name, if applicable. 6. Obtain all physician signatures and license numbers t be included n yur applicatin, if applicable. 7. See the SC Nurse practice Act fr guidelines n the develpment f written prtcls. 8. Applicatin fees Mney rder, cashier s check r persnal check made payable t LLR-Bard f Nursing. $30.00 - Update frm current SC RN license t APRN (Permanent license nly) $40.00- Update frm current SC RN license t APRN with temprary license 9. Applying fr Prescriptive Authrity-cmplete and submit: Prescriptive Authrity Applicatin- see www.llr.state.sc.us/pl/nursing Dcumentatin f 45 cntinuing educatin hurs in pharmactherapeutics 10. Check the status f yur applicatin nline at www.llr.state.sc.us/pl/nursing. Allw 10 business days fr prcessing after receipt f yur applicatin in the bard s ffice. Als allw 10 business days after receipt f the last dcument fr a license number t be generated. During peak times, the applicatin review/apprval prcess may take lnger. 2. Change f Address - The Bard shuld be ntified f all changes in address, name and/r telephne number. Yu must ntify the Bard in writing immediately after yu file this applicatin in rder t receive infrmatin frm the bard. 3. Change in Supervising Physician r Place f Practice - It is f utmst imprtance that yu infrm the Bard f any changes in yur supervising physician r place f practice. The Suth Carlina Nurse Practice Act 40-33-34(D)(3) requires a licensed APRN wh changes r discntinues primary practice settings r physician r dentist t ntify the bard f this change within 15 business days and prvide verificatin f apprved written guidelines. Failure t ntify the Bard f changes in practice shall be cnsidered miscnduct and subject the licensee t disciplinary actin. 4. Name Used n License - All licenses are issued in the applicant s legal name. Yur legal name is yur first name, middle name r maiden name, if married, and last 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 certified 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 - 40-33-34 (D)(3) & (H)(4) f the S.C. Nurse Practice Act requires that licensed APRN wh change r discntinue practice settings r physician (r dentist) shall ntify the Bard f such change within 15 days and prvide verificatin f apprved written prtcls (guidelines). Failure t ntify the Bard f a change in practice shall be cnsidered miscnduct and subject the licensee t disciplinary actin. 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 respnsibility f the licensee t renew their license. D nt wait until renewal time t ntify the Bard f a change in yur address, supervisr 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 requirements fr renewal. ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 2 f 12

Remember: Prir t cmpleting applicatin, review Sectin 40-33-34 f the Nurse Practice Act fr statutry requirements fr licensure as an Advanced Practice Registered Nurse (APRN) in Suth Carlina. The Nurse Practice Act can be fund under Laws/Plicies n ur website www.llr.state.sc.us/pl/nursing/ If yu were previusly licensed by the SC Bard f Nursing as an APRN, d nt use this applicatin frm. Visit Applicatins/Frms n the Bard s web page fr a Reactivatin/Reinstatement Applicatin t reinstate yur APRN license. Please print clearly in black ink. Cmplete the Affidavit f Eligibility. Cashier s check, mney rder r persnal check shuld be made payable t LLR-Bard f Nursing. Dcuments (marriage licenses and ther legal dcuments) are part f yur applicatin file and are nt returned. Ntify the Bard immediately f any change in name r address changes during the applicatin prcess. Cpies f legal dcuments that authrize a change in name. Sign, date yur pht n the frnt r back and tape alng the tp edge nly nt yur applicatin. Clr r black and white phts are accepted. Review and cmplete CBC requirements. If yu need a fingerprint card, please e-mail NurseBard@LLR.SC.GOV. Dcument f earned master s degree. Have fficial transcripts sent directly frm yur master s nursing educatinal prgram t the SC Bard f Nursing. Supply a cpy f a current advanced practice nursing specialty certificatin by 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. See the SC Nurse Practice Act [ 40-33-34] and the SC 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. Check the status f yur applicatin nline n the Bard s website. 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. Applicatins are maintained n file fr ne year; all fees are nn-refundable. Applicants applying fr Prescriptive Authrity, cmplete and submit: Prescriptive Authrity Applicatin- see www.llr.state.sc.us/pl/nursing Dcumentatin f cntinuing educatin hurs in pharmactherapeutics Prescriptive authrity will nt be granted until the fee has been received, educatinal requirements are met; supervising physician signatures are btained and prf f natinal certificatin has been received). Any questins regarding this applicatin shuld be directed t the SC Bard f Nursing at (803) 896-4550. ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 3 f 12

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: IDENTOGO CARDSCAN DEPARTMENT 6840 CAROTHERS DRIVE STE 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. ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 4 f 12

APPLICATION FOR ADVANCED PRACTICE REGISTERED NURSE (APRN) UPDATING FROM CURRENT SOUTH CAROLINA RN LICENSE TO SC APRN LICENSE 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 disclsure f the scial security number fr identificatin purpses is authrized and mandated by state and federal statutes. The scial security number is nt subject t disclsure as public infrmatin. 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 (NP) Certified Nurse-Midwife (CNM) Certified Registered Nurse Anesthetist (CRNA) 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 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. Hispanic/Spanish Origin Caucasian/White Other 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. ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 5 f 12

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 FROM (Mnth/Year) TO (Mnth/Year) DID YOU COMPLETE PROGRAM Y N HIGHEST GRADE COMPLETED OR DEGREE EARNED Y N Y N 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 If yes, Accredited by: Graduate Nursing Prgram Accredited? Yes 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.) State f Original Jurisdictin Credential Type (LPN, RN r APRN) (Initial) Licensure: List Other Jurisdictins f Licensure: License Number/Name n License Hw License Obtained (Type f Exam r Endrsement) Date Issued ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 6 f 12

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 ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 7 f 12

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? NA NA 11. a. D yu plan t prescribe Schedules III thrugh V? NA 1. Specialty area f APRN practice. PART VII: Specialty Area(s) & Certificatin(s) 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) (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. Other 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? ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 8 f 12

PART VIII: Advanced Practice Emplyment (Current) PRIMARY Practice Site (If mre than 2 sites, duplicate frm as needed) 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. ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 9 f 12

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 Subscribed and swrn t befre me this day f, 20. Signature f Ntary Public My Cmmissin Expires: Tape pht at tp nly Attach recent passprt pht here 2 x 2 N cpies Sign and date pht D nt staple DID YOU REMEMBER TO: Cmplete and answer all questins. Sign, date and have applicatin ntarized. Cmplete the Affidavit f Eligibility (Next 2 pages) Sign, date yur pht n frnt r back and tape alng tp edge nly nt yur applicatin. Black & white phts are acceptable. Enclse nn-refundable applicatin fee - Mney rder, cashier s check r persnal check made payable t LLR-Bard f Nursing. N cash accepted. $30.00 - Update frm current SC RN license t APRN (Permanent license nly). $40.00- Update frm current SC RN license t APRN and temprary license. Cpy f current SC RN License. Dcument f earned master s degree (See Nurse Practice Act). Have fficial transcripts sent directly frm yur master s f nursing educatinal prgram t Bard f Nursing. Cmplete the criminal backgrund check prcess. Cpy f 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). See the SC Nurse practice Act fr guidelines n the develpment f written prtcls Obtain all physician signatures and license numbers t be included n yur applicatin, if applicable. If applying fr Prescriptive Authrity, cmplete and submit: Prescriptive Authrity Applicatin- see SC BON web site www.llr.state.sc.us/pl/nursing Dcumentatin f cntinuing educatin hurs in pharmactherapeutics (prescriptive authrity will nt be granted until the fee has been received, educatinal requirements are met; supervising physician signatures are btained and prf f natinal certificatin has been received). Cpies f legal dcuments that authrize a change in name. 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. Fr Office Use Only Paid by: Check Mney Order Check/Mney Order N: Amunt: Cntrl N. ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 10 f 12

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) being first duly swrn depses and states as fllws: 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.) 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: ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 11 f 12

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) ADVANCED PRACTICE REGISTERED NURSE (APRN) Applicatin (Rev 03/15) [www.llr.state.sc.us/pl/nursing/] 12 f 12