Nurse Form 1 at a glance
What it is: Nurse Form 1 is the Application for Licensure of the Office of the Professions, The State Education Department.
Notary: The Affidavit with Acknowledgement (Notarization required): this form must be signed and dated in the presence of a Notary Public.
All applicants for licensure must complete this form and submit it with the appropriate fee ($143) directly to the Office of the Professions (checked October 31, 2026).
A filled-in Nurse Form 1 example: a nurse applies for a license
How to fill out Nurse Form 1, box by box
Check what you are applying for
Check what you are applying for (check one): Registered Professional Nurse or Licensed Practical Nurse.
1. Social Security Number, 2. Birth Date, 3. Print Name
Enter your Social Security Number in Box 1. Leave it blank if you do not have a U.S. Social Security Number.
Enter your Birth Date in Box 2 as Month, Day and Year.
Print your Last, First and Middle name in Box 3.
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).
4. Mailing Address Home or Business
Enter your Mailing Address, Home or Business, in Box 4 on Line 1, Line 2 and Line 3, with City, State, ZIP Code and Country/ Province. You must notify the Department promptly of any address or name changes.
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.
5. Telephone/Email Address
In Box 5, enter your Daytime Phone as Area Code and Phone, and your Email Address (please print clearly), and mark Home or Business for each.
6. New York State DMV ID Number
Enter your New York State DMV ID Number (Driver or Non-Driver ID) in Box 6. Leave this blank if you do not have a New York State DMV ID Number.
7. CGFNS record, 8. Name as it appears on degree, 9. New York State licensure
Box 7: Do you have a CGFNS record? Yes or No. If "yes", enter your CGFNS Number.
In Box 8, enter your name as it appears on degree or other credentials (if different from above).
Box 9: Have you ever applied for New York State licensure in any profession? Yes or No. If "yes", in what profession(s)?
15. License or certificate to practice any profession
15. Do you now hold, or have you ever held, a license or certificate to practice any profession in any state or jurisdiction? Yes or No. If yes, list each license/certificate with its Professional Title, State or Jurisdiction, Date License/Certificate Issued, License/Certificate Number and Limitations on License/Certificate.
A Form 3 or Nursys license verification must be submitted for each professional license/certificate listed unless it is a license/certificate issued by the New York State Education Department.
16. Name of School
16. You must complete all information for all schools/colleges/universities attended or your application will be considered incomplete.
Name of School, City, State/Province, Country, Number of years attended, Attendance from and to, and Completion date go in each of Elementary or Primary School, High School/Secondary School or Equivalency Diploma Issuer, Nurse Program and Postsecondary Education. Nurse Program and Postsecondary Education also ask for Major/Concentration, Title of Degree/Diploma/Certificate awarded (in original language) Or Still in progress, and Date Degree/Diploma/Certificate awarded.
If you are applying for licensure as a licensed practical nurse and you did not graduate from a New York State approved nursing program, you must submit a copy of your high school or secondary school diploma or transcript in the original language with your Form 1.
19. Citizenship/Immigration Status
19. Citizenship/Immigration Status: check the appropriate box which indicates your citizenship/immigration status.
I am: A. A United States citizen or National. B. An alien lawfully admitted for permanent residence in the United States. H. Non Immigrant (Temporarily in U.S.): Please list Visa type or immigration status or attach a copy of your passport if you are not required to have a Visa to enter the United States. J. I do not reside in the United States.
If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship and Immigration Services (USCIS): USCIS number.
22. Reasonable Testing Accommodations
22. Reasonable Testing Accommodations for Individuals with Disabilities. (check if applicable): I have been diagnosed as having a disability and require special testing accommodations and am submitting the Request for Reasonable Testing Accommodations form.
25. Affidavit with Acknowledgement (Notarization required)
Affidavit: "I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I understand that any false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure and may result in criminal prosecution."
Under Applicant, SIGN and enter the Date. Under Notary, enter State of, County of, On the day of, in the year, the Applicant name on the personally appeared line, Notary Public's Signature, Notary ID number, Expiration Date and Notary Stamp.
More rules for Nurse Form 1
Box 10: Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or misdemeanor) in any court?
Box 11: Are criminal charges pending against you in any court? Yes or No.
Box 13: Are charges pending against you in any jurisdiction for any sort of professional misconduct? Yes or No.
Box 14: Has any hospital, licensed facility or clinical laboratory restricted or terminated your professional training, employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures?
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. While your application is pending, you must notify the Division of Professional Licensing Services if the answers to any of these questions have changed.
18. Child Support Obligation: everyone applying for a professional license, permit, or registration, or any renewal thereof, must certify that, as of the date of the filing, she or he is, or is not, under an obligation to pay child support.
CHECK ONLY A OR B. A: I am not under an obligation to pay child support. B: I am under an obligation to pay child support and (please check only one of the following).
If you check B, you must check one of the five statements. I am current and am not four months or more in arrears in the payment of child support. I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties. The child support obligation is the subject of a pending court proceeding. I am receiving public assistance or supplemental security income. None of the four statements apply.
20. Child Abuse Identification and Reporting Coursework Requirement - RN Applicants Only (check one): I graduated from a NYS registered program and completed the child abuse identification training as part of my studies. I completed the child abuse coursework and have enclosed a certificate of completion from an approved provider. I completed the child abuse coursework online and the approved provider will report that to you electronically. I am filing for an exemption to the requirement and have enclosed the Certification of Exemption (Form 1CE).
21. Infection Control Training Requirement (check one): I graduated from a NYS registered licensure qualifying program within the last four years and completed the infection control training during my studies. I completed the infection control training within the last four years and have enclosed a certificate of completion from an approved provider. I completed the infection control training online within the last four years and the approved provider will report that to you electronically. I am filing for an exemption to the requirement and have enclosed an Attestation of Infection Control Training (Form 1IC).
Common questions about Nurse Form 1
Where do I file it?
If you are submitting an initial Form 1, mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201, U.S.A. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Are there fees?
The $143 fee is the total of the application fee ($70) plus the fee for your first registration period ($73) (checked October 31, 2026). The application portion of the fee is not refundable.
Sources
[1] Nurse Form 1 (Revised 11/19), Application for Licensure, New York State Education Department, Office of the Professions (the Official source link on this page).