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ARMED

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L I C E N S I N G

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Are you the spouse of a veteran of the United States Armed Services? Are you the spouse of an active member of the United States Armed Services?

If you answered “Yes” to any of these questions, you may qualify for a reduction in

Health’s commitment to serving members and veterans of the United States Armed

Forces and their families online at

Nurse Licensure Compact State Information

Florida is a member of the Nurse Licensure Compact (NLC). The NLC allows a registered nurse or licensed practical nurse licensed in a Compact State to practice across state lines in another Compact State without having to obtain a license in the other state unless the nurse moves and declares the new Compact State as their new primary state of residence. It is important to understand that the NLC requires nurses to adhere to the nursing practice laws and rules of the state in which they practice under their Compact license. The Compact does not include Advanced Practice Registered Nurses. If a nurse moves from one state to another and establishes residency, the nurse must apply for licensure in that state. Visit the National Council of State Boards of Nursing (NCSBN) website https://www.ncsbn.org/nurse-licensure-compact.htm for a list of states that have implemented the Compact.

Who is Eligible to Apply for Licensure by Examination?

Graduates from:

Florida approved nursing education programs as defined in section (s.) 464.003, Florida Statutes (F.S.).

Accreditation Commission for Education in Nursing (ACEN) or Commission on Collegiate Nursing Education (CCNE) accredited nursing programs that have been issued a National Council Licensure Examination (NCLEX) code by the National Council of State Boards of Nursing (NCSBN).

Nursing education programs that have been approved or recognized by the jurisdiction in which it is based and that has been issued an NCLEX code by NCSBN.

Military nursing programs* that have been issued an NCLEX code by NCSBN.

Generic Master of Science in Nursing (MSN) or higher programs that have been issued an NCLEX code by NCSBN.

A non-NCSBN jurisdiction or international education program that the Board of Nursing determines is equivalent to an approved program.

Practical Nurse examination based on practical nurse equivalency (PNEQ)- Applicants who have successfully completed courses equivalent to practical nursing education in a registered nursing program (See Nursing Education History, Section 7 in the application for more information).

Canadian Registered Nurses who took the Canadian Nurse Association Testing Service (CNATS) Examination after August 8, 1995 must take the NCLEX unless licensed in another U.S. state or territory. If test scores are in an acceptable range approved by the Board of Nursing, Canadian Registered Nurse applicants who took the CNATS prior to August 8, 1995 may be eligible for endorsement. Unless licensed in another U.S. state or territory, or have taken the NCLEX, Canadian Licensed Practical Nurses are required to apply by examination.

*Other military health related programs (not issued an NCLEX code by NCSBN) are not equivalent to professional nursing programs in Florida. Programs completed to qualify as a hospital corpsman, technician, physician or a physician’s assistant are not classified as registered or practical nursing programs and are not equivalent.

Important Information: In addition to applying for licensure with the board, all applicants must register with Pearson VUE and pay the fee. All fees paid to Pearson VUE are nonrefundable. You may view the NCLEX Candidate Bulletin and register with Pearson VUE online at www.vue.com/nclex or by telephone at

1-866-496-2539. Failure to register for the examination with Pearson VUE will delay the approval of your Authorization to Test (ATT). Applicants should register with Pearson VUE prior to approval by the board, except for applicants educated outside the United States, who should wait for board approval.

DH‐MQA 1094, Revised 6/2020, Rule 64B9‐3.002, F.A.C.

Page 3 of 22

Pearson VUE

Applicants who register with Pearson VUE after they have been made eligible must contact the board office to report their registration. This notification is necessary to ensure approval is sent to Pearson VUE.

Changing your address may cause you to be turned away from your examination. To avoid delays, you should notify the board office of any address changes in writing as soon as possible. Address changes can be emailed to mqa.nursingappstatus@flhealth.gov.

Any applicant who does not take their scheduled examination within 90 days of the Authorization to Test (ATT) being issued must re-register with Pearson VUE and notify the board office. The board is not able to grant extensions.

The name and address listed on your application and provided to Pearson VUE must match the identification that you intend to provide on the day of your examination.

When you arrive at the test center, you will be required to present your ATT Letter and Acceptable Identification.

If you arrive without these materials, or the materials do not match, you will be turned away and will be required to re-register and repay Pearson VUE’s examination fee of $200.00

Several security measures will be enforced during the administration of the examination. Strict candidate identification requirements have been established by NCSBN. Find out more at https://www.ncsbn.org/1213.htm. Only the identification listed below will be accepted:

U.S. Driver License

Provincial/Territorial or State Identification Card

Passport (The only identification acceptable for testing centers outside the U.S.)

U.S. Military Identification

Permanent Residence Card

All identification, including temporary identification*, must:

Be valid	Include a photograph
Not expired	Contain your name in Roman characters
Include a signature	Be government-issued

* Examples of temporary identification include limited term IDs and any ID reading “temp” or “temporary.”

Graduate Nurse Status

An applicant approved for Graduate Nurse (GN) Status may practice nursing before passing the NCLEX. Applicants with GN status must practice nursing under the direct supervision of a registered nurse. Direct supervision is defined as the physical presence within the patient care unit of a registered nurse who assumes legal responsibility for the nursing practice of graduate nurses.

GN Status is only valid within three months of graduation. To qualify for GN status you must apply to the Florida Board of Nursing and be approved. Applicants who graduated three months or more prior to submitting their application will not be eligible for GN status. Applicants who do not pass the first examination lose their GN status and are no longer eligible for employment in that capacity. Employers will require you to present your eligibility letter from the board and your ATT from Pearson VUE.

DH‐MQA 1094, Revised 6/2020, Rule 64B9‐3.002, F.A.C.

Page 4 of 22

Nursing Licensure by

Examination Application

Board of Nursing

P.O. Box 6330

Tallahassee, FL 32314-6330

Fax: 850-617-6460

Email: mqa.nursingappstatus@flhealth.gov

Do Not Write in this Space For Revenue Receipting Only

Per s. 464.008(3), F.S., any applicant who has failed a licensing examination three consecutive times, regardless of jurisdiction in which the examination was taken, shall be required to complete a board approved remedial course. https://floridasnursing.gov/education-and-training-programs/florida-board-of-nursing-approved-remedial-courses/

Select application type:	Total fee of $110.00 includes the following:
Registered Nurse (RN) 1701- $110.00	Processing Fee	$50.00
Licensed Practical Nurse (LPN) 1702- $110.00	Initial Licensure Fee	$50.00
Licensed Practical Nurse (LPN) 1702- $110.00	Student Loan Forgiveness Fund	$5.00
	Unlicensed Activity Fee	$5.00

Fees must be paid in the form of a cashier’s check or money order, made payable to the Department of Health. An applicant who is denied licensure or withdraws their application is entitled to a $60.00 (Initial Licensure Fee, Student Loan Forgiveness Fund, and Unlicensed Activity Fee) refund. Fees are refundable for up to three years from the date of receipt.

1. PERSONAL INFORMATION

Name: ______________________________________________________________________			Date of Birth: _______________
Last/Surname	First	Middle	MM/DD/YYYY

Mailing Address: (The address where mail and your license should be sent)

_____________________________________________________ ________ _______________________________

Street/P.O. BoxApt. No. City

_____________________________ _________ _____________________ ________________________________

State

ZIP

Country

Home/Cell Telephone (Input without dashes)

Physical Location: (Required if mailing address is a P.O. Box- This address will be posted on the Department of Health’s website.)

_____________________________________________________ _________ ______________________________

StreetApt. No. City

________________________________ _________ ___________________ _______________________________

State

ZIP

Country

Work/Cell Telephone (Input without dashes)

EQUAL OPPORTUNITY DATA:

We are required to ask that you furnish the following information as part of your voluntary compliance with 41 CFR Part 60-3-Uniform Guidelines on Employee Selection Procedure (1978); 43 FR 38295 and 38296 (August 25, 1978). This information is gathered for statistical an d reporting purposes only and does not in any way affect your candidacy for licensure.

Gender:	Male	Race:	Native Hawaiian or Pacific Islander	Hispanic or Latino	White
	Female		American Indian or Alaska Native	Black or African American	Asian
			Two or More Races

Email Notification: To be notified of the status of your application by email check the “Yes” box and fill in your email address on the line provided. If you choose to be notified via email you will be responsible for checking your email regularly and updating your email address with the board office.

Yes

Email Address: ____________________________________________________

Under Florida law, email addresses are public records. If you do not want your email address released in response to a public records request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing.

DH‐MQA 1094, Revised 6/2020, Rule 64B9‐3.002, F.A.C.

Page 5 of 22

2. SOCIAL SECURITY DISCLOSURE

This information is exempt from public records disclosure.

Pursuant to Title 42 United States Code § 666(a)(13), the department is required and authorized to collect Social Security Numbers relating to applications for professional licensure. Additionally, s. 456.013(1)(a), F.S., authorizes the collection of Social Security numbers as part of the general licensing provisions.

Last Name: _____________________________________________________________

First Name: _____________________________________________________________

Middle Name: ___________________________________________________________

Social Security Number: __________________________________________________

(Input without dashes)

Social Security Information- * Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, § 653 and 654; and s. 456.013(1), 409.2577, and 409.2598, F.S. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to ensure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for license identification pursuant to Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act. 104 Pub. L. Section 317). Clarification of the SSA process may be reviewed at www.ssa.gov or by calling 1-800-772-1213.

Board of Nursing

4052 Bald Cypress Way Bin C‐02

Tallahassee, FL 32399‐3252

You may apply for licensure before obtaining a Social Security number. However, you will not be issued a license until proof of a U.S. Social Security number is received.

_____________________________________________________________________________________

3.SPECIAL TESTING ACCOMMODATIONS

Applicants must have a qualifying medical condition in order to receive special accommodations. Applicants requiring special accommodations should verify that the accommodations are available prior to scheduling their examination.

Do you require special testing accommodations?

Yes

Applicants who require special accommodations should be aware that the process to have accommodations approved is quite lengthy, usually taking a minimum of 60 days. To apply for special accommodations, download the information booklet at http://www.floridasnursing.gov/special-testing-accommodations or contact the Special Testing Coordinator at (850) 245-4252. Accomodation requests must be sent to:

Department of Health, Division of Medical Quality Assurance

Bureau of Operations, Attention: Special Testing Coordinator

4052 Bald Cypress Way, Bin C‐90

Tallahassee, FL 32399‐3260

DH‐MQA 1094, Revised 6/2020, Rule 64B9‐3.002, F.A.C.

Page 6 of 22

Name: _____________________________________________

4.NURSE LICENSURE COMPACT (NLC)

Requirements that must be met in order to qualify for a multistate license from Florida:

Florida must be the Primary State of Residence*

Florida’s requirements for initial licensure must be met

License status must be clear and unencumbered **

Must not have a felony conviction***, regardless of adjudication

Must not be enrolled with the Intervention Project for Nurses (IPN) or any other treatment program for impaired practitioners

Must have a U.S. Social Security number

Terminology:

*Primary state of residence is defined by the Compact as the “person’s declared fixed permanent and principal home for legal purposes; domicile."

**Encumbrance means “revocation or suspension of, or any limitation on, the full and unrestricted practice of nursing, imposed by a licensing board.”

***Felony conviction is defined as being “convicted or found guilty, or has entered into an agreed disposition other than a disposition that results in nolle prosequi, for a felony offense under applicable state or federal criminal law.”

Proof of primary residence may include but is not limited to:

Driver license with a home address

Voter registration card displaying a home address

Federal income tax return declaring the primary state of residence

W2 from U.S. Government or any bureau, division, or agency thereof indicating the declared state of residence

A. Do you declare Florida to be your primary state of residence and are you providing a Florida address?

Yes No

If you do not have a current Florida mailing address, and wish to have a multistate license, you must provide one of the documents listed above. If Florida is not your primary state of residence, you are not eligible for a Florida multistate license and your application will be processed for a single state license.

B. Do you hold an active NLC multistate license in another state?

Yes

A nurse may only hold one multistate license. If your declared primary state of residence is another Compact state and you are not changing your primary residence to Florida, you are not eligible for a multistate license in Florida and should not submit this application, as your NLC license allows you to practice in Florida.

DH‐MQA 1094, Revised 6/2020, Rule 64B9‐3.002, F.A.C.

Page 7 of 22

Name: _____________________________________________

5.APPLICANT BACKGROUND

A.List any other name(s) by which you have been known in the past. Attach additional sheets if necessary.

_______________________________________________________________________________________

B.What name did you use when you were first licensed? ___________________________________________

C. Have you ever applied for nursing licensure in Florida?					Yes		No
If “Yes,” complete the following:
	Application Method			License Type			Date (MM/DD/YYYY)
Examination		Endorsement		LPN	RN
Examination		Endorsement		LPN	RN
D. Have you ever held a nursing license in Florida?				Yes		No
If “Yes,” complete the following:
License Type			Date (MM/DD/YYYY)
LPN	RN
LPN	RN

E.Do you hold, or have you ever held a license to practice nursing or any other health-related license(s)?

Yes No

F.List all health-related licenses (active, inactive or lapsed).

License

Type

License # State/Country

Original Date

Issued

(MM/DD/YYYY)

Expiration

Date

(MM/DD/YYYY)

Status of License

6. DISASTER

Would you be willing to provide health services in special needs shelters or to help staff disaster medical

assistance teams during times of emergency or major disaster?

Yes

DH‐MQA 1094, Revised 6/2020, Rule 64B9‐3.002, F.A.C.

Page 8 of 22

Name: _____________________________________________

7.EDUCATION HISTORY

A. List the nursing school(s) you attended.

School Name:	School Address: (Street, City, State, ZIP, Country)

Graduation Date*	Degree Awarded:	Diploma	LPN	ADN	BSN
(MM/DD/YYYY):	Degree Awarded:	Diploma	LPN	ADN	BSN
(MM/DD/YYYY):

School Name:	School Address: (Street, City, State, ZIP, Country)

Graduation Date*
Graduation Date*	Degree Awarded:	Diploma	LPN	ADN	BSN
(MM/DD/YYYY):	Degree Awarded:	Diploma	LPN	ADN	BSN
(MM/DD/YYYY):

*Graduation date or anticipated graduation date.

B.What name(s) did you use when you received your nursing education?

______________________________________________________________________________________

Practical Nurse Equivalency

Applicants who have successfully completed courses equivalent to practical nursing education in a professional nursing program may qualify for NCLEX-PN based on practical nurse equivalency (PNEQ). All professional courses taken must have been successfully completed with a grade of “C –” or better and must have included theory and clinical instruction. The professional or practical nursing curriculum must document clinical experience and theoretical instruction in medical, surgical, obstetric, pediatric, and geriatric nursing. Each curriculum plan must document clinical training experience in appropriate settings that include, but are not limited to, acute care, long-term care, and community settings.

Only LPN PNEQ applicants- Place a checkmark here if you did not graduate from the RN program you attended and are applying for NCLEX-PN based on PNEQ, as defined above. Do not check if you are in or graduated from an LPN program.

PNEQ applicants are required to have their school submit the following items directly to the board office:

Official Transcripts

Course Descriptions

Practical Nurse Equivalency Application Letter (found at the back of the application)

Documentation must be mailed to:

Board of Nursing

4052 Bald Cypress Way Bin C‐02

Tallahassee, FL 32399‐3252

DH‐MQA 1094, Revised 6/2020, Rule 64B9‐3.002, F.A.C.

Page 9 of 22

Name: _____________________________________________

Applicants educated outside the U.S., or Graduates from U.S. Territories whose regulatory nursing board is not a member of the National Council of State Boards of Nursing (NCSBN) are required to have a full education credentials review by a Florida board-approved credentialing agency.

An original copy of the credentials report must be sent electronically to the board directly from the agency. The board does not accept paper copies. Applicants are responsible for paying all fees the agency charges for these services.

Credentials reports received from a credentialing agency not listed below will not be accepted.

Board-Approved Education Evaluation Providers

Ashland Educational Services	Educational Records Evaluation Service, Inc.
Foreign Credentials Evaluation Agency	601 University Avenue, Suite 127
15192 S.W. 137 Street, Suite 10	Sacramento, CA 95825-6738, USA
Miami, FL 33196, USA	Phone: (916) 921-0790 or (866) 411-3737 (Toll Free)
Phone: (786) 457-4608	Fax: (916) 921-0793
Email: Admin@AshlandEducationalServices.com	Email: edu@eres.com
Web: http://ashlandeducationalservices.com/	Web: www.eres.com

Josef Silny & Associates, Inc.	Commission on Graduates of
International Education Consultants	Foreign Nursing Schools
7101 S.W. 102 Avenue	3600 Market Street, Suite 400
Miami, FL 33173, USA	Philadelphia, PA 19104-2641, USA
Phone: (305) 273-1338	Applicant Inquiries: (215) 349-8767
Fax: (305) 273-1338	Customer Service Fax: (215) 622-0425
Email: info@jsilny.org	Automated Phone System (to check status):
Web: www.jsilny.org	(215) 599-6200
	Email: info@cgfns.org
	Web: www.cgfns.org

DH‐MQA 1094, Revised 6/2020, Rule 64B9‐3.002, F.A.C.

Page 10 of 22

Question	Answer
Form Name	Florida Board Nursing Application
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	Mqa, florida board of nursing application pdf, re examination application for nclex rn florida, florida

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