Vermont Secretary of State Office of Professional Regulation 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing Foreign_nurse@sec.state.vt.us www.vtprofessionals.org Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE LICENSE BY NCLEX ENDORSEMENT (International) Applicant must submit the following: 1. Complete Vermont Application. 2. Application Fee of $150.00 (n-refundable Processing Fee) a. We accept check, money order, demand draft, or travelers check. b. Payment must be U.S Funds from bank with a United States affiliate. 3. Verification of Licensure Provide verification of your original nursing license as well as the nursing license from your most recent state of nursing employment. If those states are members of NURSYS, go to www.nursys.com and obtain license verification(s) for Vermont. (te: The Quick Confirm Report does not suffice.) If those states do not participate in electronic verification through NURSYS, use the additional pages 8 & 9 to complete the verification requests. 4. Copy of passport or United States identification. 5. A copy of your current and original RN license showing expiration date 6. A Copy of the NCLEX-RN Candidate Report with photo. a. If you do not have a copy of the NCLEX-RN Candidate Report with a photo you will need to request in writing to the state board where you took and passed the NCLEX for a copy of this report. b. Fees may apply. 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. Credentials Evaluation Information International Education Research Foundation, Inc. P.O. Box 3665 Culver City, CA 90231 Website: www.ierf.org Email: alliedhealth@ierf.org Phone: 310-258-9451 Applicants apply for a Vermont specific Credentials Evaluation Service (CES) report. CGFNS International 3600 Market Street, Suite 400 Philadelphia, PA 19104-2651 USA Website: www.cgfns.org Phone: 215-349-8767 Applicants apply for the Vermont Specific Professional Credentials Evaluation Service (CES) report. When applying to CGFNS for a Vermont Specific CES report: Follow the instructions on the CGFNS website, section 13b and indicate Vermont Board of Nursing as the second recipient for the Professional CES report. When applying to IERF for a Vermont Specific CES report: Follow the instructions on the IERF website. For Applicants who already hold a CGFNS Certificate: You must also submit a Vermont-specific CES report. For RN s whose nursing program was NOT taught in English: In order to apply to the State of Vermont, you must have successfully completed an English Proficiency Exam. Submit a copy of your certificate of completion along with your application to the Board office. tice: The State of Vermont is currently not accepting RN applications from applicants educated in Haiti. Effective 9/10/08
Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT 05620-3402 Licensing Board Specialist Foreign_nurse@sec.state.vt.us www.vtprofessionals.org Vermont Board of Nursing Registered Nurse NCLEX Endorsement Application -International 2x2 Recent Photo- Paste Here Application Fee: $150.00 (nonrefundable) 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 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. 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 Office of Professional Regulation 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. 3
Section D: Have you ever taken the NCLEX-RN exam? If yes, please attach copies of your NCLEX-RN results and complete the following: Through which state did you take the NCLEX-RN: Number of times the NCLEX-RN was taken: Date NCLEX-RN was taken: Section E: I have graduated from my nursing education program within the last five (5) years: Date of Graduation: (MM/DD/YYYY) Name of Nursing School Nursing School Mailing Address: City State/Country Zip/Postal Code Section F: I have practiced as a registered nurse as defined in 26 V.S.A. 1576(c); Administrative Rules Part 6.8(g) for at least (check the appropriate statement): 120 days (960 hours) in the last 5 years or 50 days (400 hours) in the last 2 years I have not worked as a registered nurse in the last 2 or 5 years. 4
Position # 1 (most recent) Your Job Title Paid or Volunteer? Full Time Part Time Date of Employment Name of Agency/Institution From (MM/DD/YYYY) To (MM/DD/YYYY) P.O. Box Mailing Address Street/Apt # City/State/Zip/Country Agency/Institution Phone # Supervisor s Name and Title Position # 2 Your Job Title Paid or Volunteer? Full Time Part Time Date of Employment Name of Agency/Institution From (MM/DD/YYYY) To (MM/DD/YYYY) P.O. Box Mailing Address Street/Apt # City/State/Zip/Country Agency/Institution Phone # Supervisor s Name and Title 5
If you practiced as a registered nurse in a private duty capacity or as a volunteer, attach: Private Duty: 1. An Official letter from the Attending Provider on their letter head, stating that RN care was required. The letter must clearly list the Providers name, title, contact telephone number and have their signature. 2. A letter from your Employer or Client, verifying your role and duties as a Private Duty Nurse. They must verify the number of days, hours and dates worked. The letter must clearly list the Employer/Clients name, contact telephone number, email address, mailing address and have their signature. Volunteer: 1. An Official letter from your Employer sent directly to the Vermont Board of Nursing office from the Director of Nursing or Director of Human Resources. A copy of your Job Description as a Volunteer Nurse, and a letter listing the number of days, hours and dates worked. The letter must clearly list the name of the Director of Nursing or Director of Human Resources, their telephone number, email address, mailing address and have their signature. I hereby certify that I understand that my application will not be complete without completing a Vermont-specific Credentials Evaluation Service (CES) Report. I understand that my application must be completed within one year. Check off the statement below that applies to you: I will be obtaining a CES Report from: CGFNS IERF I have already sent a CES Report from: CGFNS IERF All required documents must be received by this office within 6 months of receipt of this application. If application remains incomplete after 6 months it will be destroyed. If you are interested in reapplying, a new application and fee must be submitted. 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: Vermont Board of Nursing Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier, VT 05620-3402 6