nclex application vermont

Vermont Board of Nursing Office of Professional Regulation

National Life Bldg, North FL 2 Montpelier, VT 05620-3402

802-828-1380

Graduates of International Nursing Schools Application for Licensure by Examination/Endorsemen t

Instructions

Please carefully read these instructions before submitting your application for a Vermont RN or LPN license.

• For graduates of nursing programs (preparing RNs) c onducted in English. Please complete the application below. This Office will conduct an internal transcript and licensure review. At times we are unable to verify the comparability of a nursing program located outside of the United States to Vermont requirements. If that circumstance occurs, we will notify you.

OR

• For graduates of LPN programs located outside of th e United States or for RN’s whose nursing program was NOT taught in English. Please complete the application below and request a Course-by-Course Credentials Evaluation Service Report (CES)from the Commission on Graduates of Foreign Nursing Schools. You may register with CGFNS at www.cgfns.org or contact them at 215-349-8767. Your application will be reviewed when the CES is received and all other required application materials are on file in this Office.

Please note:

• Application forms are inspected on the date of receipt. • Applications are returned if the fee is not included. • Applications will not be reviewed if all sections are not completed. • Applications will be reviewed to determine eligibility for the NCLEX only after all required

information is on file in this Office. • The review process takes up to 3 or 4 months.

To complete your Vermont application you must: 1. Complete Pages 1 through 7

a. Line by line instructions are provided below b. Complete all sections c. Fill in all blanks

2. Submit the Application fee of $150.00 payable to: Vermont Secretary of State.

a. Payment must be In US funds from a bank with a Unit ed States affiliate. b. The $150.00 must come with the application or the application will be returned. c. Payment can be sent in the form of check, money order, demand draft or travelers

check. d. Payment is not refundable. e. Have your name written somewhere on the check.

3. Request the Director of your nursing program (or other authorized officer) to complete,

sign and return the “Verification of Education” form. a. The form must be stamped and sealed with an official school seal. b. Please note: This is not required for applicants who are obtaining a CGFNS certificate

or CES report.

4. Request the Registrar or Director of your nursing program to send an official, certified transcript (including clinical transcripts/related learning experiences). a. The transcript must be stamped and sealed with an official school seal. b. Please note: This is not required for applicants who are obtaining a CGFNS certificate

or CES report.

5. Request your country’s licensing body to send a certified statement of your current licensure status (see instructions on Verification of Licensure page). This should be certified, sealed in an envelope by the licensing body and included with your application packet. (If you are licensed in a country that will not release this directly to you, please have them send it directly to us after your application has been submitted so that it can be matched with your file). We need this verification for your original license and your most current license (if in a different country).

6. Submit one recent passport type photograph

a. Photo must be (2 X 2) in size, head and shoulders only. b. Attach photo to application.

7. Submit a copy of your current nursing license

a. The license must be in good standing and show an expiration date. b. Please note: If you do not hold a current nursing license you are not eligible to take

the NCLEX through Vermont. c. Please note: If you are a Philippine applicant and do not yet hold a license, but hold a

board pass letter, have the Philippine Regulatory Commission send a certified copy of the letter directly to our office, and simply write “Philippines- letter requested” in the area provided. You will have to provide a copy of your nursing license prior to being licensed in Vermont. Along with the pass letter, you will also need the PRC to certify that your license application is in good standing.

8. Submit a copy of your original license (if from a different country than your current

license). 9. Submit a photocopy of your passport (just the open face page).

a. Be sure that the copy provided is clear and easy to read. b. Please note: Write your name on the Vermont application exactly as it appears

on your passport, or you will not be able to sit fo r the exam. Line by Line Instructions : (Fill out all sections. Do not leave any blanks) Page 1: • Enter your name exactly as it appears on your passport. • Please provide an email address

• Add our email address ([email protected]) to your address book so that if we contact you via email, it does not get filtered to junk mail.

• Please note: If an applicant is represented by an Agency – Only the Agency may contact the Office. All correspondence related to the applicant will be sent directly to the agency.

• Completely fill out your school’s contact information, including their full address, the degree you earned, and the date you graduated. This information is all required.

Page 2: • Indicate how many hours you have worked as a nurse in the last 5 years. Do not leave this

section blank unless you have not worked at all during that time period. o Please note: If you graduated from your nursing program within the last 5 years and

have not worked at all, you may leave the section blank. • Provide your license information. If you do not hold a license, you are not eligible to sit for

the exam through the State of Vermont. o Please note: If you are a Philippine applicant and do not yet hold a license, but hold a

board pass letter, have the Philippine Regulatory Commission send a certified copy of the letter directly to our office, and simply write “Philippines- letter requested” in the area provided. You will have to provide a copy of your nursing license prior to being licensed in Vermont. Along with the pass letter, you will also need the PRC to certify that your license application is in good standing.

• You must answer ALL of the questions which follow on this page. If you have taken the NCLEX one or more times, be sure to let us know the date(s) and in which state(s). Also include copies of your fail letters (with photos) with this application. You can obtain those letters from the Board of Nursing in the State through which you took the exam.

Pages 3 and 4: • You are required to answer the questions concerning child support and taxes.

o If you are not a US resident, the most common answer to the child support questions is “no”, and to the tax questions is “yes”, unless you have other relevant information for either section.

• You must provide a Social Security Number if you have one. • If you do not have a Social Security Number, you must provide passport information instead. • You must sign and date this page. Pages 5 and 6: • Applicants must fill out the first block on this page and then submit the form to their school of

nursing. • The school will then send the form either to the applicant or directly to Vermont. The form

MUST be in an envelope sealed by the school in order to be accepted by the State of Vermont.

Page 7: • You must fill out the verification of licensure form and send it to your country’s licensing body

for verification. Please review your application carefully . Failure to follow all of these instructions very carefully will result in an incomplete or incorrect application and will slow the process. Guidelines for Contacting this Office:

• To check your application status, check the website. www.vtprofessionals.org • Our email auto-reply will tell you which month is currently being processed. If you email

asking for the status of an application that is not currently being processed, your email will not be responded to other than with the auto reply.

• To change your address, send an email with your full name and new address. • For queries on applications more than 5 months old, email and either the auto-reply will

answer your question or we will respond. Please be sure to state your full name and the date your application was received in the email.

• Questions that can be answered by looking at the website or the application form itself will not be responded to through email.

• We do not look up application status over the phone or email unless there is something wrong with the application or it has been over 5 months since the application was received.

Ready to submit your application? Use the following checklist to be sure you have included everything you need.

� Included the $150 fee � Included a 2x2 inch photo � Included email address (if applicable) � Filled out educational information � Filled out work history information � Filled out license and passport information � Answered question concerning whether or not you have taken the NCLEX � If you have taken the NCLEX, you have included copies of your fail letters from the

Board of Nursing you took the exam through � Included copy of passport � Included copy of CURRENT license or certified (sealed in an envelope) Regulatory

Commission Board Pass Letter � Included copy of original license (if from different country than current). � Included certified, sealed verification of valid licensure (in good standing) � Answered ALL legal questions � Signed application � Sent verification of education to school with request for transcripts

Updated 09/23/08-lp

Board of Nursing - Vermont Secretary of State - Office of Professional Regulation National Life Building, North, Floor 2, Montpelier, VT 05620-3402

E-Mail: [email protected] Web: www.vtprofessionals.org

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Application for Licensure as a: _____ Registered N urse ______ Practical Nurse Type or Print. When space is insufficient, attach additional sheets.

Last Name (Surname /Family Name) (As on Passport) First Name MI Form er/Maiden

Mailing Address - Street

City State Country Postal Code

Telephone: Fax: E-Mail: Date of Birth

*Note: Please add our email address ([email protected]) to your email address book so that when we email you it does not get filtered to your bulk/junk mail folders.

Agency – If applicable list Agency Name and Address E-Mail:

Address City State Postal Code

Nursing Education: Name, City & State of College/U niversity Attended - Institution must also complete the Nursing Educatio n Certification form.

Degree Earned

Date Graduated (mm/dd/yyyy)

Name: ____________________________________________________________

____________________________________________________________

Address:___________________________________________ _________________

____________________________________________________________

Email: _____________________________ Phone:___ _____________________

2”X2” Recent Photo



2

I have practiced nursing as defined in 26 V.S.A. § 1576, for at least (check the appropriate statement ): 120 days (960 hours) in the last 5 years 50 days (400 hours) in the last 2 years

Position #1 (most recent) Place of Employment City State Country

Dates of Employment: From: To:

Job Title:

Position #2 (if applicable) Place of Employment City State Country

Dates of Employment: From: To:

Job Title:

You must have either worked as a nurse as stated ab ove or have graduated within the last 5 years in or der to qualify to sit for the NCLEX through the State o f Vermont.

Country of Original Licensure License # Date Issu ed Date Expires(d)

Country of Current Licensure (if different) License # Date Issued Date Expires

Circle Yes or No. A yes requires a written explana tion, and/or other documentation 1. Have you been convicted of a crime other than a minor traffic violation? If "yes," explain

and attach the court documents, if any. YES NO

2. Has Vermont, any other state, territory, or o ther jurisdiction, denied your application for a license, certificate, or registration in any prof ession or occupation? If the answer is "yes", provide a certified copy of the action .

YES NO

3. Has Vermont, any other state, territory, or o ther jurisdiction, restricted, suspended, revoked, or taken any other disciplinary action aga inst a license, certificate, or registration that you hold or held in any professio n or occupation? If the answer is "yes", provide a certified copy of the action.

YES NO

Circle Yes or No. A yes requires a written explana tion, and/or other documentation. Answers to thes e Questions are not subject to public disclosure.

1. Do you have a physical or mental condition or di sorder which in any way impairs or limits your ability to practice with reasonable ski ll and safety? If yes, provide a physician's statement or medical confirmation of th e disability.

YES NO

2. Does your use of alcohol, drugs, or medications in any way impair or limit your ability to practice with reasonable skill and safety?" If yes, please explain in detail. YES NO

3. 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 yes, please provide the contract/stipulation und er which your are practicing.

YES NO



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1. Have you ever taken the NCLEX exam? If you answered “Yes” please let us know what state you have taken NCLEX through and include a copy of your results with this applicatio n. Candidates who do not retake the examination within two years but less than five years of the initial examination may retake the examination only after completing an entire approved nursing program. If you took your first NCLEX over five years ago you are not eligible to apply in the state of Vermont. State:

YES NO

Number of times the exam was taken: Dates the exam was taken:

If you have failed the NCLEX, include copies of you r fail letters (with photos) with this application. You can obtain those letters from the Board of Nursing in t he State through which you took the exam.

Applicant's Statements Regarding Child Support Answer This Question: 1. I am subject to an order to pay child support. If you answered “Yes”, proceed to question 2. If “No”, proceed to question 3.

YES NO

2. I am in full compliance with a plan to pay any a nd all child support due to the State of

Vermont If you answered “Yes”, proceed to question 3. If “ No”, you must contact the Office.

YES NO

Applicant's Statements Regarding Taxes, Unemploymen t Compensation Contributions Answer This Question: 3. I am in good standing with respect to or in full compliance with a plan to pay any and

all taxes due to the State of Vermont If you answered “Yes”, proceed to question 4. If “ No”, you must contact the Office.

YES NO

Answer This Question: 4. I am in good standing with respect to or in full compliance with a plan to pay any and

all unemployment contributions due to the State of Vermont. If you answered “Yes”, proceed to complete the rene wal. If “No”, you must contact the Office.

YES NO

A Social Security Number is NOT required if you are not a U.S. citizen and do not have a Social Security Number. Social Security # ________/______/__________ * The disclosure of your social security number is mandatory, it is solicited by the authority grante d by 42 U.S.C. ' 405 (c)(2)(C), and will be used by the Departments of Taxes, Child Sup port and Employment and Training in the administrat ion of Vermont law, to identify individuals affected by such laws. YOUR S OCIAL SECURITY NUMBER IS NOT SUBJECT TO DISCLOSURE AS PART OF A PUBLIC RECORDS REQUEST.



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A Passport Number IS required if you do not have a Social Security Numb er. Passport #: ____________________Country of Issue: _ __________________Expiration Date:____________

Statement of Applicant I hereby certify that all information I have provid ed in this application is true and accurate to the best of my knowledge. I understand that furnishing false info rmation may constitute unprofessional conduct and result in the denial of my application for licensur e or further disciplinary sanction. Signature: Date:



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Verification of Education – Attach Stamped Official Transcript and Clinical Transcripts This page and the following page must also be stamp ed by the school

Applicant: Complete the box below and have the Sch ool of Nursing complete this page and the page foll owing.

Last Name Fir st Name MI Former/Maiden Name (As on Application AND Passport ) (On School Documents )

Mailing Address – Street City State Zip Date of Birth

I hereby authorize the School of Nursing to furnish to the Board of Nursing the information requested below. Signature Date

Information Below To Be Completed by the School of Nursing: (Attach Official Transcript and Detailed Course Descriptions)

Name of Nursing School

Mailing Address

Program Commenced (mm/dd/yyyy) Date of Graduation ( mm/dd/yyyy) Degree/Certificate Earned

Summary of Theoretical Education and Clinical Pract ice Hours

Was the language of instruction and textbooks for t he nurse’s program in ENGLISH?

YES NO

Clinical Area of Practice

Theory Hours

Course Title/Number (REQUIRED)

Clinical Hours


Care of the Adult- Medical Nursing

Care of the Adult-Surgical Nursing

Maternal/Infant Nursing

Psychiatric/Mental Health Nursing

Pediatric Nursing/Care of the Sick Child:



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Support Courses: Theory Hours


Clinical Hours


Anatomy and Physiology

Microbiology

Psychology

Print Name

Date

Telephone Position/Title

Email

Signature of Dean/ Director

Official School

Seal/Stamp

Further Information: If the course titles do not m atch the subjects as they are listed on this form (in the specific language w e use) it is very important that you fill out the columns showing us in which c ourses (or modules) the theory and clinical experience for each subject was taught and for how many hours of in each course. We cannot approve an applicant without this information. Note: Please sign and place official school stamp o n BOTH pages of this form. Thank you.



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Verification of Licensure- To Be Filled Out By Nurs ing Regulatory Body

Last Name: First Name: Middle Initial: Country of Licensure: License Number: License Issue Date: License Expiry Date:

Is this License considered to be In Good Standing? (please circle) YES NO If no, what is its current status (valid, expired, revoked, suspended, or conditioned)? Are there any conditions that apply to the license and what are they? Please comment below. Use additional pages if necessary. Certifying/Regulatory Body Name: Individual Name: Date:

Place seal/stamp of

Certification here.

This form should be sealed in an envelope by the regulating body and returned to the license holder. 9-11-08 lcp