Nurse Form 1Nys – Fill Out and Use This PDF

The University of the State of New York

This Area For Department Use Only

Nurse Form 1

The State Education Department

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

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

Middle

Daytime Phone

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