Lpn License Ga Details

If you are a nurse who has had their license revoked in the state of Georgia, don't worry! There is a form that you can fill out to have your license reinstated. This form is called the Georgia Reinstatement Nursing Form, and it can be found on the Georgia Board of Nursing website. In order to complete this form, you will need to provide information about why your license was revoked, as well as what steps you have taken to correct the issue.

We've gathered some basic information about the georgia reinstatement nursing. You can study it before filling in the form.

QuestionAnswer
Form NameGeorgia Reinstatement Nursing
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesga board of nursing, reinstate ga nursing license, georgia nursing license reinstatement form, georgia rn license reinstatement form

Form Preview Example

APPLICATION FOR REINSTATEMENT OF LICENSE

GEORGIA STATE BOARD OF ACCOUNTANCY

237 Coliseum Drive

Macon, GA 31217

Phone (478) 207-2440

www.sos.georgia.gov/plb/accountancy/

Please read the instructions carefully and be familiar with the laws and rules governing the practice of accountancy in the State of Georgia. Visit the following website for information: www.sos.georgia.gov/plb/accountancy/. Board Rule 20-10-.04 concerning reinstatement of licensure is enclosed within this application.

The Board cannot process incomplete applications. If any item is missing, incomplete or incorrect, your application cannot be reviewed by the Board. Please review the check list below and this application before you submit it to ensure that all information and documentation is complete and correct.

Consent Form for background check. This form must be completed, signed and returned with your application or your complete application will be returned.

Activities Since Last Renewal. Field must be completed. Answers could be: did not need, out of country, sick, etc.

Non-refundable application fee of $150.00 (check or money order) made payable to Georgia State Board of Accountancy

Reason For Failing To Renew. Field must be completed.

Required completed hours of continuing professional education for reinstatement.

See the table below on left for the required number of hours required for reinstatement of license. If you do not have the required hours, your complete application will be returned and you have 90 days from the date of the notification letter to re-submit the application without an additional fee.

CPE Requirements:

You are required to have obtained 40 hours of CPE per year, not to exceed 160 hours. You may be required to show proof of this only if randomly audited.

See Board Rule 20-11-.02 (1) for more information regarding CPE.

A minimum of 20% of total hours must be in accounting and auditing subjects and at least 80 hours must have been earned during the 24 months immediately preceding the date of the Reinstatement Application. (Reinstatement Application must be signed the date it is mailed.) For instance: If you sign the Reinstatement Application on 1/1/08, your 80 hours (with 16 hrs. in A&A) would be from 1/1/06 to 1/1/08. Hours earned in 2008 and 2009 may also be used for the 12/31/09 renewal year. CPE requirements must be completed before submitting the Reinstatement Application.

As information:

If your license lapsed 12/31/07, you may use hours from 1/1/06 and forward for all hours except for the recent 80 hours in the previous 24 months (with 20% in A&A).

If you license lapsed 12/31/05, you may use hours from 1/1/04 and forward for all hours except for the recent 80 hours (with 20% in A&A) in the previous 24 months.

C:\Users\dmickler\AppData\Local\Temp\22 Application for Reinstatement of License_6D05F61.doc

1 of 8

For Board Use Only

Date of Review

Approved

Disapproved

For Board Use Only

Fee Paid

 

 

 

Check #

 

 

 

 

 

 

 

 

 

Date

 

 

 

Applicant #

 

Receipt

#

 

 

 

 

 

 

GEORGIA STATE BOARD OF ACCOUNTANCY

237 Coliseum Drive - Macon, Georgia 31217 - (478) 207-2440

www.sos.state.ga.us/plb/accountancy/

APPLICATION FOR REINSTATEMENT OF LICENSE

(Application will be returned if all questions are not answered)

Reinstatement Fee: $150.00 (Non-Refundable)

License Type

PLEASE PRINT OR TYPE

Certified Public Accountant

License No.

 

Date License Lapsed

1.Name on License

 

First

Middle

Last

2. SSN*

 

3. Date of Birth

 

*THIS INFORMATION IS AUTHORIZED TO BE OBTAINED & DISCLOSED TO STATE & FEDERAL AGENCIES PURSUANT TO O.C.G.A. SECTION 19-11-1 & O.C.G.A.SECTION 20-3-295, 42 U.S.C.A. SECTION 551 & 20 U.S.C.A.SECTION 1001.

4.Physical Address

Number and Street (P.O. Box not acceptable)Apt. No.City/StateZip

5.

Mailing Address

 

 

 

 

 

 

 

 

 

(if different than Street address)

 

 

 

 

 

 

 

 

 

 

 

 

Street, P.O. Box

 

Apt. No.

City/State

Zip

6.

Telephone Number Day

 

(

)

Telephone Number Evening

(

)

 

7.Present Employer

8.Business Address

Number and Street

City

State

Zip

9.Internet e-mail address

Since the date of your last renewal, have you been convicted of a felony or misdemeanor (other than a minor traffic violation), or entered a plea of guilty, nolo contendere, or sentenced under the First Offender Act, or been sanctioned by this or another state board or agency? If Yes, check below and attach copy of conviction, plea or sanction. DUI and DWI are not minor traffic offenses.

NO

YES

(If YES, attach a certified copy of conviction, plea or sanction)

ACTIVITIES SINCE LAST RENEWAL:

C:\Users\dmickler\AppData\Local\Temp\22 Application for Reinstatement of License_6D05F61.doc

2 of 8

REASON FOR FAILING TO RENEW:

APPLICANT AFFIDAVIT:

I hereby swear and affirm that all information provided in this application is true and correct to the best of my knowledge and belief. I further swear and affirm that I have read and understand the current state laws and rules and regulations of the Board for which I am applying for licensure and I agree to abide by these laws and rules.

By executing this affidavit under oath, as an applicant for a professional license, as referenced in O.C.G.A. § 50-36- 1, administered by the Professional Licensing Boards Division, the undersigned applicant also verifies one of the following with respect to his/her application for a public benefit (check one):

1)

 

I am a United States citizen. Please submit a copy of your current Secure and Verifiable

 

 

Document(s) such as driver’s license, passport, or document as indicated on the Board’s

 

 

website.

2)

 

I am not a United States citizen, but I am either a legal permanent resident of the United States or I

 

 

am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an

 

 

alien number issued by the Department of Homeland Security or other federal immigration agency.

Please submit a copy of your current immigration document(s) which includes either your Alien number or your I-94 number and, if needed, SEVIS number.

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit.

In making the above representations under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute. I also understand that any failure to make full and accurate disclosures may result in disciplinary action by the Board for which I am applying for licensure.

Executed in

 

(city),

 

(state).

Signature of Applicant

Printed Name of Applicant

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE

DAY OF

 

_, 20

NOTARY PUBLIC My Commission Expires:

C:\Users\dmickler\AppData\Local\Temp\22 Application for Reinstatement of License_6D05F61.doc

3 of 8

IMPORTANT: Please see the following for continuing professional education report & page 8 for copy of rule #20-10- 04.

CONTINUING PROFESSIONAL EDUCATION REPORT

NAME :

THIS PAGE MUST HAVE TOTALS FOR A & A HOURS AND ALL OTHER SUBJECTS HOURS. APPLICATION WILL BE RETURNED IF THESE COLUMNS ARE NOT COMPLETE. THE BOARD WILL NOT TOTAL YOUR CPE HOURS.

(See page 8 for copy of rule #20-10-.04 (REINSTATEMENT) effective January 25, 2001 for current requirement.) YOU ARE NOT REQUIRED TO SUBMIT DOCUMENTATION OF CONTINUING EDUCATION HOURS UNLESS YOU ARE AUDITED.

School, Firm or Organization Conducting Program

Title of Program or Description of Content

Principal Instructor

Dates Attended

Accounting & Auditing

All Other Subjects

C:\Users\dmickler\AppData\Local\Temp\22 Application for Reinstatement of License_6D05F61.doc

4 of 8

School, Firm or Organization Conducting Program

Title of Program or Description of Content

Principal Instructor

Dates Attended

Accounting & Auditing

All Other Subjects

Sub Total Hours

TOTAL HOURS CLAIMED ABOVE 2 COLUMNS MUST BE COMPLETED

I certify under penalty of perjury to the truth and accuracy of all statements, answers and representations made in this report.

Signature

Date

C:\Users\dmickler\AppData\Local\Temp\22 Application for Reinstatement of License_6D05F61.doc

5 of 8

OFFICE OF SECRETARY OF STATE

PROFESSIONAL LICENSING BOARDS DIVISION

237 Coliseum Drive

Macon, Georgia 31217

(478) 207-2440

CONSENT FORM

I hereby authorize the State Board of Accountancy (“Board) to receive any Georgia criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.

Full Name (Print)

Physical Address

(P.O. Boxes NOT Accepted)

 

 

 

 

 

 

 

 

 

 

 

 

Sex

Race

 

Date of Birth

Social Security Number

One of the following must be checked:

 

 

 

This authorization is valid for 90/180/

 

(circle one) days from date of signature.

I,

 

 

 

give consent to the Board to perform periodic

criminal history background checks for the duration of my licensure with this state.

Signature of Applicant

Date

Special licensure provisions (check if applicable):

Working with mentally disabled

Working with elder care

Working with children

C:\Users\dmickler\AppData\Local\Temp\22 Application for Reinstatement of License_6D05F61.doc

6 of 8

APPLICANT: PLEASE CHECK THE FORM OF IDENTIFICATION BELOW THAT YOU POSSESS. RETURN THIS FORM ALONG WITH A COPY OF YOUR APPROPRIATE DOCUMENTATION.

Name

Secure and Verifiable Documents Under O.C.G.A. § 50-36-2

Issued August 1, 2011 by the Office of the Attorney General, Georgia

The Illegal Immigration Reform and Enforcement Act of 2011 (IIREA) provides that [n]ot later than August 1, 2011, the Attorney General shall provide and make public on the Department of Law’s website a list of acceptable secure and verifiable documents. The list shall be reviewed and updated annually by the Attorney General.O.C.G.A. § 50-36-2(f). The Attorney General may modify this list on a more frequent basis, if necessary.

The following list of secure and verifiable documents, published under the authority of O.C.G.A. § 50-36-2, contains documents that are verifiable for identification purposes, and documents on this list may not necessarily be indicative of residency or immigration status.

A United States passport or passport card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A United States military identification card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A driver’s license issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the

Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

An identification card issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A tribal identification card of a federally recognized Native American tribe, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer. A listing of federally recognized Native American tribes may be found at: http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/index.htm [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

An Employment Authorization Document that contains a photograph of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A passport issued by a foreign government [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A Free and Secure Trade (FAST) card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

A NEXUS card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A. §50-36-2(b)(3); 22 CFR § 41.2]

A driver’s license issued by a Canadian government authority [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

A Certificate of Citizenship issued by the United States Department of Citizenship and Immigration Services (USCIS) (Form N-560 or Form N-561) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration Services (USCIS) (Form N-550 or Form N-570) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

In addition to the documents listed herein, if, in administering a public benefit or program, an agency is required by federal law to accept a document or other form of identification for proof of or documentation of identity, that document or other form of identification will be deemed a secure and verifiable document solely for that particular program or administration of that particular public benefit. [O.C.G.A. § 50- 36-2(c)]

C:\Users\dmickler\AppData\Local\Temp\22 Application for Reinstatement of License_6D05F61.doc

7 of 8

RULES OF THE GEORGIA STATE BOARD OF ACCOUNTANCY

20-10-.04 REINSTATEMENT

20-10-.04 Reinstatement. Amended.

(1)An application for reinstatement of an expired permit shall be accompanied by:

(a) A reinstatement fee of $150.00; and

(b)Evidence satisfactory to the Board, of the completion of continuing professional education as specified below:

1.Forty hours of continuing professional education for each year since the last renewal of the permit or since the initial issuance of the permit, whichever is less, up to a maximum of 160 hours.

2.At least twenty percent of the total hours required must be earned in accounting and auditing subjects.

3.At least 80 of the continuing professional education hours must have been completed during the 2-year period immediately preceding the date of application for reinstatement.

4.The hours required may be counted toward fulfilling the continuing professional education requirements for the next biennial renewal, if they were completed during the applicable period for renewal.

5.No carryover hours may be used to satisfy continuing professional education requirements for reinstatement of an expired permit.

(c)The Board may, however, accept in lieu of the continuing professional education requirements other evidence of continued competency including, but not limited to, the passing of an examination approved by the Board.

(2)In considering the application for reinstatement the Board may conduct an investigation of the applicant to determine, among other things, if the applicant engaged in the practice of public accountancy during the period that the applicant was not the holder of a live permit to practice public accountancy. Based on the results of that investigation, the Board may deny the application for reinstatement.

C:\Users\dmickler\AppData\Local\Temp\22 Application for Reinstatement of License_6D05F61.doc

8 of 8

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .