Nurse Form 1Nys is a very important document for nurses in the state of New York. This form must be completed and filed with the New York State Department of Education within 30 days of starting work as a nurse in New York. The form can be found on the department's website, and it must be filled out completely in order to avoid any potential penalties. Completing this form is also a requirement for nurses who wish to renew their license or certification. Keep reading for more information on Nurse Form 1Nys and what it entails.
We've gathered some useful information about the nurse form 1nys. There, you will discover the information about the PDF you would like to fill out, including the estimated time to complete it and also other data.
| Question | Answer |
|---|---|
| Form Name | Nurse Form 1Nys |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | nysed form 1, ny nurse form 1, nurse form 1 application for licensure, new york state board of nursing application |
|
Nurse |
The University of the State of New York |
|
THE STATE EDUCATION DEPARTMENT |
|
|
Form 1NYS |
Office of the Professions |
|
Division of Professional Licensing Services |
|
|
|
www.op.nysed.gov |
|
|
Application for Licensure
ONLY for NYS Approved Nursing Program Graduates
If you DID NOT graduate from a NYS approved nursing program
DO NOT use this form
Applicants Must Complete All Pages of This Application In Ink
Graduates of NYS approved nursing programs must complete this form and submit it with the appropriate licensure and registration fee ($143) directly to the Office of the Professions at the address at the end of this form to apply for licensure in NYS. You must answer all questions and provide all information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review. Your signature on this form must be notarized by a Notary Public.
11. Check what you are applying for:
|
|
Registered Nurse License |
|
|
|
|
22 |
$143 |
|
ER |
|
|
LPN Applicants: Be sure to |
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
attach a copy of your High |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
Licensed Practical Nurse License |
|
10 |
$143 |
|
ER |
|
|
School or GED Diploma. |
|||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2 |
Social Security Number |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
2. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
3 |
Birth Date |
Month |
|
|
|
|
Day |
|
|
|
|
|
Year |
|
|
|
|
|
|
|
||||
|
3. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
4.Print Name
Last
First
Middle
5. Mailing Address (You must notify the Department promptly of any address or name changes using the Address/Name Change Form which can be found on our Web site at www.op.nysed.gov/anchange.pdf.)
Line 1
Line 2
Line 3
City
State |
|
|
Zip Code |
|
|
|
|
Country/
Province
Department Use Only
NYS License Number
Date Issued
Initials
6.
Daytime phone
Area Code |
Phone |
67.New York State DMV ID Number (Driver or
78. REASONABLE TESTING ACCOMMODATIONS FOR INDIVIDUALS WITH DISABILITIES. (Check the box below if applicable)
I have been diagnosed as having a disability and require accommodations for testing. I am separately submitting the Request for Reasonable Accommodations form to: Office of the Professions, Professional Examinations Unit, Education Building, Room 304EB, 89 Washington Avenue, Albany, NY 12234. I understand that I will not be able to test with accommodations until my request form and documentation have been submitted and my request is approved. You may obtain a copy of the Request for Reasonable Accommodations form at www.op.nysed.gov/pls1ra.pdf.
9
8.
Name of nursing school and city where located: ______________________________________________________________________
(Reminder: DO NOT use this form unless you graduated from a NYS approved nursing program)
Name as it appears on degree or other credentials (if different from item 4): ________________________________________________
109.
Have you previously applied for New York State licensure in any profession? |
Yes |
No |
If “yes”, in what profession(s)? _______________________________________________________________
110.
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? |
|
|
121. |
Are criminal charges pending against you in any court? |
Yes |
No |
132. |
Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, 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? |
Yes |
No |
|
Nurse Form 1NYS, Page 1 of 3, Rev. 12/11 |
|
|
143.
Are charges pending against you in any jurisdiction for any sort of professional misconduct? |
Yes |
No |
14.
15
Has any hospital or licensed facility 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? |
Yes |
No |
NOTE: If you answer "Yes" to any questions numbered
165.
Do you now hold, or have you ever held, a license or certificate to practice any profession* in any jurisdiction? Yes No
If yes, list each license/certificate, state or jurisdiction and provide appropriate information in the columns below. A Form 3 (found on our Web site at www.op.nysed.gov/nurseforms.htm) must be submitted for each license/certificate listed unless it is a license/certificate issued by the New York State Education Department. See the Applicant Instructions on Form 3 for specific information about completing and submitting the form.
Professional Title
State or Jurisdiction
Date License/Certificate
Issued
License/Certificate
Number
Limitations
On License/Certificate
*Profession is defined as professional titles licensed under New York State Education Law. For a list, go to www.op.nysed.gov
17
16. Child Support Obligation
Everyone applying for a professional license, permit, or registration, or any renewal thereof, must file a written statement that, as of the date of the filing, she or he is, or is not, under an obligation to pay child support*. Individuals who are four months or more in arrears in child support or who have failed to comply with a summons, subpoena or warrant relating to a paternity or child support proceeding may be subject to suspension of their business, professional, drivers and/or recreational licenses and permits. The intentional submission of false written statements for the purpose of frustrating or defeating the lawful enforcement of support obligations is punishable under section 175.35 of the Penal Law.
You must complete this section before we can issue the credential for which you have applied. Individuals who are not in compliance with their obligation to pay child support can be issued a credential for no more than six months in order to comply with their child support obligations.
Check only A or B below. If you check B, you must check one of the five statements listed below it.
A.I am not under an obligation to pay child support
OR
B.I am under an obligation to pay child support and (please check only one of the following)
I am current and am not four months or more in arrears in the payment of child support; or,
I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties; or, The child support obligation is the subject of a pending court proceeding; or,
I am receiving public assistance or supplemental security income; or, None of the above four statements apply.
* New York State General Obligations Law, section
18
6. Student Loan Disclosure
The State Education Department is required* to ask these questions about any student loans made or guaranteed by the New York State Higher Education Services Corporation, and to forward any "yes" responses to the New York State Higher Education Services Corporation. Your license application is not complete without this information.
A) |
Do you have any outstanding loans made or guaranteed by the New York State Higher Education |
Yes |
No |
|
Services Corporation? |
|
|
B) |
If you have such a loan(s), is any part in default? |
Yes |
No |
*New York State Education Law, Section
19
19. Gender and Ethnicity: (This item is optional.)
Information on gender and ethnicity is sought solely to allow the Education Department to collect and analyze data concerning diversity in the licensed professions. The ethnic and gender data you provide will be used only for statistical, research, and program evaluation purposes. It will not be released to the public. This information has absolutely no bearing on your qualification for licensure.
Gender: |
Male |
Female |
|
|
|
Ethnicity: |
White (not Hispanic) |
Black (not Hispanic) |
Asian |
Hispanic |
Native American |
Nurse Form 1NYS, Page 2 of 3, Rev. 12/11
20. Citizenship/Immigration Status:
Federal law limits the issuance of professional licenses, registrations and limited permits to United States citizens or qualified aliens. To comply with this Federal law, complete this section of this form and check the appropriate box below which indicates your citizenship/immigration status.
Iam:
A.A United States citizen or National.
B.An alien lawfully admitted for permanent residence in the United States.
C.An alien granted asylum under Section 208 of the Immigration and Nationality Act.
D.A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
E.An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1 year.
F.An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
G.An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April 1980.
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: _______________________________________
I.I do not reside in the United States.
If you checked any of the boxes from
Citizenship and Immigration Services (USCIS): |
USCIS number: ___________________________________________ |
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL LAW SHOULD BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING
21. Education Program Review
I give permission to the New York State Education Department to release my examination results to my professional school for the confidential purposes of program review and institution research and planning. I may rescind this authority at any time by notifying the Division of Professional Licensing Services in writing.
Yes
No
Please initial: _____________________
22
24.
Affidavit And Acknowledgment (Notarization required.)
Applicant
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.
Signature of the applicant: ______________________________________________________________________________________
Date: _______ / _______ / _______
mo. |
day |
yr. |
Notary
State of __________________________________________________ County of __________________________________________
On the ____________ day of ______________________ in the year __________ before me, the undersigned, personally appeared
__________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual
whose name is subscribed to this application and acknowledged to me that he/she executed the application and swore that the
statements made by him/her in the application and all supporting materials are true, complete, and correct.
Notary Public signature: _________________________________________________________________________________________
Notary ID number: _______________________________
Notary Stamp
Expiration date: _______ / _______ / _______
mo. |
day |
yr. |
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Nurse Form 1NYS, Page 3 of 3, Rev. 12/11
Dear NYS Nurse Program Graduate,
To help us process your application as quickly as possible, PLEASE:
•Complete each question on this form carefully and accurately and return the completed application with the $143 fee for licensure and first registration to the Office of the Professions at the address indicated at the end of the form;
•After submitting your completed application to us, apply online to Pearson VUE to take the appropriate examination at www.vue.com/nclex/;
•Be sure to provide your Social Security Number on both the licensure application and the examination application as this will enable Pearson VUE to process your authorization to test (ATT).
Thank you!