Secretary Of State Nurse Practitioner – Fill Out and Use This PDF

Georgia Board of Nursing – Initial Authorization

as an Advanced Practice Registered Nurse

Please follow these easy steps to ensure that your application is processed as quickly as possible.

1.Complete the application in its entirety. Indicate N/A for any blanks that are not applicable.

2.Include a check or money order payable to the Georgia Board of Nursing in the amount of $75.00. Please note that application fees are non-refundable.

3.Board rules chapter 410-11 require applicants for authorization as an APRN to be currently licensed by the Georgia Board of Nursing as a registered nurse in the state of Georgia.

4.Board rules chapter 410-11 require applicants for authorization as an APRN to be certified by one of the national certifying bodies recognized in Board Rule 410-11-.12. Please request your national certifying body to submit verification of national certification to the Georgia Board of Nursing at nursing@sos.ga.gov.

5.Submit official transcripts from your nursing education program which document graduation from an accredited APRN program. To avoid processing delays please submit your transcripts as part of your application packet. Transcripts may also be sent electronically to nursing@sos.ga.gov by the school or using a transcript exchange service.

6.Board rules chapter 410-11 require applicants for authorization as an APRN to document one of the following: 1) Graduation from

an advanced practice nursing education program within four years of the date of application; 2) Five hundred (500) hours of practice as an advanced practice registered nurse (based on the definition of “Advanced Nursing Practice” found in O.C.G.A. §43-26-3) within the

four years preceding the date of this application; or, 3) Completion of a Board approved advanced practice reentry program as described in Board Rule 410-4-.04. Have your employer complete and notarize the attached “Verification of Employment Form” or

submit a copy of your transcripts documenting graduation from an accredited APRN education program to provide documentation of active practice within the four years preceding the date of this application. To avoid processing delays please submit verifications of employment or transcripts as part of your application packet.

7.The Board requires applicants to disclose all previous arrests, history of treatment for substance abuse or dependence and discipline by other regulatory boards. If you have ever been arrested, received treatment, or been disciplined by any other regulatory board or agency please provide a certified copy of the official documents showing the final disposition or order relevant to the incident as well as a personal, detailed letter of explanation regarding each incident. If you are required to submit treatment information please include all information relevant to your diagnosis, prognosis, treatment plan, practice recommendations and discharge summary. To avoid processing delays please submit all documentation as part of your application packet.

8.Georgia law requires applicants to submit secure and verifiable documentation regarding their United States citizenship status. Submit a copy of your driver’s license, United States passport or other document as indicated on page 3 of the application packet. To avoid processing delays please submit the required documentation as part of your application packet.

9.Have your completed and signed application notarized.

10.Mail your completed application to the Georgia Board of Nursing for processing. Applications are processed in the order in which they are received. To avoid processing delays please be sure to include all required documentation with your application packet. Applications are valid for one year from the date of submission. When mailing your application please use a 9x12 envelope and do not fold or staple any of the documents.

You must not engage in practice as an advanced practice registered nurse in Georgia until you are authorized by the Georgia Board of Nursing. Any person practicing or offering to practice nursing or using the title “advanced practice registered nurse,” as defined in

O.C.G.A. §§ 43-26-1 et.seq. within the State of Georgia, shall be authorized as provided in O.C.G.A. §§ 43-26-1 et.seq.

August 2020

Please check this box if you are a military spouse or a transitioning service member of the United States armed forces (including the National Guard).

Physical Address Information – Applicants must provide a physical address of record.

A post office box is not acceptable for this field.

Physical Address:

Mailing Address Information - Pursuant to O.C.G.A. §43-1-2(k), if issued a license, your mailing address and license number are

public information and will appear on the Board’s website. A post office box may be used for this field.

Mailing Address:

Georgia Licensure and Authorization Information

Applicants must provide information regarding their registered nursing license issued by the Georgia Board of Nursing

Georgia RN License Number:

Please select the APRN role for which you are seeking authorization.

You must submit a separate application for each authorization.

APRN Certification Information

Applicants must provide verification of national certification from one of the certifying bodies listed in Board Rule 410-11-.12.

Name of National Certifying Body:

APRN Nursing Education Information

To ensure that our licensure records contain all information regarding your APRN education please complete the section below.

APRN School Name:

Date of Graduation:

Master’s Degree  Doctorate  Other

Active Practice Information

Board Rules Chapter 410-11 require that applicants document one of the following:

I have graduated from an advanced practice nursing education program within the four (4) years preceding the date of this application:  No  Yes

I have practiced as an advanced practice registered nurse (based on the definition of “Advanced Practice Nursing” found in O.C.G.A.

§43-26-3) at least five hundred (500) hours within the four (4) years preceding the date of this application and have provided the employment information on the grid below:

 No  Yes

A completed verification of employment form must be submitted for each employer listed on this grid.

If your employer uses a third party to verify employment it is the applicant’s responsibility to obtain the employment

documentation and submit it with the application packet.

Any applicant practicing as an advanced practice registered nurse without authorization will be subject to Board review. The Board requires a personal, detailed, letter of explanation and detailed employment information from the employer’s human resources department for any advanced nursing practice in Georgia without a valid authorization.

Applicants that have not met the active practice requirement with the previous four years by graduating from an advanced practice nursing education program or practicing at least five hundred hours must complete a Board approved reentry program as defined in Board Rule 410- 4-.04.

GEORGIA BOARD OF NURSING

237 Coliseum Drive

Macon, Georgia 31217

VERIFICATION OF EMPLOYMENT FOR APPLICANTS FOR INITIAL AUTHORIZATION

Section I (To be completed by applicant)

Submit this form to your employer to verify your employment and the numbers of hours worked. The name and address of your employer on this form must match the name and address you listed under “Employment History” on your application. Ask the employer to complete this form and

place it in a sealed envelope for you to submit with your application or submit it by email to nursing@sos.ga.gov or by fax to 877-371-5712.

Physical Address:

I do hereby consent to and authorize the release of any and all records and information concerning my employment to the Georgia Board of Nursing. I understand this information is required as part of the application for licensure process.

Section II (To be completed by employer)

Please complete the form in its entirety. A separate form must be completed for each position held. Be sure to accurately document the employee’s position/title and whether or not licensure as a registered nurse was required. The completed and notarized form may be provided to

the applicant or submitted directly to the Georgia Board of Nursing by email to nursing@sos.ga.gov or by fax to 877-371-5712.

Facility/Business/Employer Name:

Physical Address:

Is this an ambulatory surgical center or obstetrical facility as defined in O.C.G.A. §31-6-2?  No Yes 

Is this a skilled nursing facility which has at least one hundred (100) beds and provides health care to patients with similar health care needs as

Is an APRN license a qualification/requirement for employment in this position?  No Yes 

If different location than the employer listed on the first page, please identify the physical location where the employee practiced

Facility/Business/Employer Name:

Physical Address:

Dates of Employment:

Employed From_________________________(Month/Year) to _________________________(Month/Year)

Were there any periods of extended absence during employment?  No Yes 

If yes, please provide dates”_________________________(Month/Year) to _________________________(Month/Year)

I hereby certify that I am the custodian of records at the facility listed on this form and the information submitted on this form are true and correct statements of this applicant’s employment with our facility.

_________________________________________________________

Employer Representative Signature

Sworn to and subscribed before me this ______ day of _____________, 20______.

- THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY -