Lvn Renewal Form – Fill Out and Use

BOARD OF VOCATIONAL NURSING & PSYCHIATRIC TECHNICIANS

2535 Capitol Oaks Drive, Suite 205, Sacramento, CA 95833-2945

Phone (916) 263-7800 Fax (916) 263-7855 Web www.bvnpt.ca.gov

4.Mail the application and fee to the above address.

PRINT OR TYPE (DO NOT USE PENCIL)

1. NAME	(LAST)	(FIRST)	(MIDDLE)
2. ADDRESS		(STREET OR BOX NUMBER)	(APT. NO)
3. CITY		STATE	ZIP

7.	LICENSE NUMBER: ____________________________________		LICENSE EXPIRATION DATE: __________________________________________
8.	IS THIS A NAME CHANGE?	□YES □NO	IS THIS AN ADDRESS CHANGE?	□YES □NO

(Note: Name changes must be submitted with evidence showing your new legal name (e.g., copy of your driver’s license, social security card, divorce decree or marriage certificate).

9. I WISH TO APPLY FOR THE FOLLOWING TYPE LICENSE:	□Inactive (Fee required is the same as fee for an active license)
□Active (Complete the continuing education information below in Section 10)

10.CONTINUING EDUCATION (CE) REQUIREMENT – CHECK ONE OF THE FOLLOWING:

□This is my first renewal. CE is not required on the first renewal.

□I have not completed the 30 hours of CE. Renew my license with an “inactive” status.

□I have completed 30 hours of CE within the last two years. My CE information is: [If additional space is required, please include it on a separate page.]

Course Name: ________________________________________________________________________________ # of Contact Hours: ____

Completion Date: _____________________________________________

Course Provider#: ____________________________

11.SINCE YOUR LAST RENEWAL, HAVE YOU HAD ANY LICENSE DISCIPLINED BY A GOVERNMENT AGENCY OR BEEN CONVICTED OR PLED GUILTY TO ANY CRIME? A conviction must be reported regardless of whether it was an infraction, misdemeanor, or felony, except that you need not report a conviction for a traffic infraction if the fine was less than $300 and the infraction did not involve alcohol or controlled substances. You must, however, disclose any conviction in which you entered a plea of no contest (Nolo Contendere) and any convictions that were subsequently set aside or dismissed pursuant to Sections 1000 or 1203.4 of the Penal Code.

□YES □NO

If “YES”, please attach explanation.

12.HAVE YOU COMPLIED WITH THE FINGERPRINT REQUIREMENT? For licenses expiring after April 1, 2009, fingerprinting is required as a condition of renewal for anyone licensed prior to January 1, 1998 or for whom a record of the submittal no longer exists.

□YES	Check the “yes” box if either 1) you were licensed on or after January 1, 1998 or 2) you were licensed before January 1, 1998 and submitted your fingerprints
□NO	on or after January 9, 2009.
	Check the “no” box if you were licensed before January 1, 1998 and did not submit your fingerprints on or after January 9, 2009. If you check “no” your
□N/A	licensewill not be renewed until you comply with the requirement to submit your fingerprints.
	Check the “n/a” (not applicable) box if you are renewing a license that expired before April 1, 2009.

13.PLEASE READ CAREFULLY BEFORE SIGNING. False statements included in this application can result in discipline against your license up to and including revocation.

"I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct."

SIGNATURE:_____________________________________________________________________ DATE:________________________________________

56R-18 (10/10)	1