New York Nurse Form 1 PDF Details

In the pursuit of a nursing career within the boundaries of New York State, every aspirant must traverse through the gateway of licensure facilitated by the Nurse Form 1. Crafted by the University of the State of New York and mandated by the State Education Department, this critical document serves as the initial application for licensure, administered by the Office of the Professions. Required to be completed in ink and with meticulous attention to detail, the form demands a non-refundable fee of $143, integrating both the application and first registration period fees. Its sections navigate through various personal and professional territories – from basic identification details, including social security and DMV ID numbers, to educational background across multiple institutions. It lays a special emphasis on legal standing by querying applicants about past convictions, pending criminal charges, and any history of licensure denial or disciplinary actions in other jurisdictions. Additionally, it delves into the applicant's history of examinations for licensure in nursing or other fields, child support obligations, and immigration status, ensuring all facets of responsibility and legality are covered. The form not only stands as a testament to the candidate's competence and integrity but also underscores New York State's commitment to maintaining high professional standards in nursing practice, ensuring that those who are granted the privilege of serving its populace are thoroughly vetted and duly qualified.

QuestionAnswer
Form NameNew York Nurse Form 1
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesnew york nurse 1, new york state nurse license application, new york form 1, rn application ny

Form Preview Example

The University of the State of New York

 

 

 

 

 

 

 

This Area For Department Use Only

 

 

 

 

 

 

 

 

 

 

 

 

The State Education Department

 

 

Nurse Form 1

 

 

 

 

 

 

Office of the Professions

 

 

 

 

 

 

 

 

 

Application for Licensure

 

 

 

 

 

Division of Professional Licensing Services

 

 

 

 

 

 

 

 

www.op.nysed.gov

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All applicants for licensure must complete this form and submit it with the appropriate fee ($143) directly to

 

 

 

 

 

the Office of the Professions at the address at the end of this form. The $143 fee is the total of the application

 

 

 

 

 

fee ($70) plus the fee for your first registration period ($73). The application portion of the fee is not refundable.

 

 

 

 

 

You must answer all questions in ink (pen or printer) and provide all information requested unless otherwise

 

 

 

 

 

indicated. Failure to complete all required parts of the application will delay its review. You must sign and date

 

 

 

 

 

the Affidavit on this form in the presence of a Notary Public.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check what you are applying for (check one):

 

 

 

 

 

 

 

 

 

 

 

 

 

Registered Professional Nurse

22

$143

ER

 

 

Licensed Practical Nurse

 

10

$143

ER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The name listed on your application for licensure, the name on your photo identification, and the name listed on your NCLEX application must ALL match EXACTLY. If your name does not exactly match in all instances it will delay your authorization to test (ATT), you may not be allowed to take the exam at your scheduled time and you may incur additional fees to test.

1.

Social Security Number

 

 

 

 

 

 

 

 

2. Birth Date

Month

 

 

 

 

 

Day

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Leave this blank if you do not have a U.S. Social Security Number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Print Name

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Telephone/Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home or

 

 

Business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Licensee business address, phone and email address are public information. Failure to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

indicate business or home on this form for each item will deem it public information.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Mailing Address

Home or

 

 

 

Business

 

 

 

 

 

Area Code

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(You must notify the Department promptly of any address or name changes)

 

 

 

 

Email Address (please print clearly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Line 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home or

 

 

Business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Line 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Line 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. New York State DMV ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Driver or Non-Driver ID)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Leave this blank if you do not have a

 

 

 

 

 

Country/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New York State DMV ID Number)

 

 

 

 

 

Province

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Do you have a CGFNS record?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If "yes", enter your CGFNS Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Name as it appears on degree or other credentials (if different from above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Have you ever applied for New York State licensure in any profession?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

If "yes", in what profession(s)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

(felony or misdemeanor) in any court?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Are criminal charges pending against you in any court?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate

 

 

 

 

 

 

 

 

 

 

 

 

held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Are charges pending against you in any jurisdiction for any sort of professional misconduct?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Has any hospital, licensed facility or clinical laboratory restricted or terminated your professional training,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association

 

 

 

 

 

 

 

 

 

 

 

 

to avoid imposition of such measures?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If you answer "Yes" to any questions numbered 10-14, submit a letter giving a complete detailed explanation. Include copies of any court records including a Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. In answering these questions, consider whether, pursuant to Executive Law § 296(16), you are required to report any arrests, criminal accusations, or dispositions of such arrests or criminal accusations. If the court can no longer provide documentation, you must request, from the court, a letter stating why they cannot provide the documents. While your application is pending, you must notify the Division of Professional Licensing Services if the answers to any of these questions have changed.

Nurse Form 1, Page 1 of 4, Revised 11/19

How to Edit New York Nurse Form 1 Online for Free

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Completing this document calls for attention to detail. Ensure that every single blank is completed correctly.

1. The new york state board of nursing application form requires certain information to be typed in. Ensure that the following blanks are complete:

Part number 1 of submitting 1 licensure form

2. Immediately after this array of fields is filled out, proceed to enter the relevant details in all these - City, State, Country Province, ZIP Code, Do you have a CGFNS record, If yes enter your CGFNS Number, Name as it appears on degree or, Have you ever applied for New, If yes in what professions, Driver or NonDriver ID, Leave this blank if you do not, Yes, Yes, Yes, and Yes.

1 licensure form writing process shown (stage 2)

When it comes to If yes enter your CGFNS Number and Name as it appears on degree or, be sure that you get them right in this current part. Both of these are the most important ones in the page.

3. This next portion is all about Do you now hold or have you ever, Yes, If yes list each, Professional Title, State or Jurisdiction, Date LicenseCertificate, LicenseCertificate, Limitations, Issued, Number, on LicenseCertificate, You must complete all information, incomplete Note If you are, Elementary or Primary School, and Name of School - complete these empty form fields.

Writing segment 3 of 1 licensure form

4. This particular part arrives with the following blank fields to complete: High SchoolSecondary School or, Name of School, City, StateProvince, Country, Number of years attended, Attendance from, Completion date, Nurse Program Please complete the, Name of School, City, MajorConcentration, StateProvince, Country, and Number of years attended.

StateProvince, StateProvince, and Name of School of 1 licensure form

5. Last of all, this final segment is precisely what you will need to finish before closing the document. The blank fields in this case are the next: Number of years attended, Attendance from, Title of DegreeDiplomaCertificate, Still in progress, Date DegreeDiplomaCertificate, and Nurse Form Page of Revised.

1 licensure form writing process clarified (portion 5)

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