RN LPN Exam Application - Wyoming State Board of Nursing

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FEES (All fees are non-refundable and subject to change) You must include payment (Cashier’s Check, Money Order, VISA, MasterCard or Discover) with your application. Name of Applicant (PLEASE PRINT): WSBN CANNOT ACCEPT PERSONAL CHECKS OR CASH. Cost Amount Criminal Background Check/Fingerprint Cards (mandatory) $ 60.00 $ 60.00 RN Application Fee $ 130.00 $ LPN Application Fee $ 130.00 $ Processing fee if paying by VISA, MasterCard or Discover (automatically assessed) $ 5.00 $ TOTAL amount due: Name, Address, and Phone Number of Individual Paying (PLEASE PRINT): Licensee Paying Third Party Paying Visa MasterCard Discover Card Number and Three Digit Security Code (on back of card): Security Code: - - - NOTE: Depending on office volume, requests could take up to 14 business days to process, providing application/request is COMPLETE. Expiration Date: By signing below, I authorize the Board of Nursing to debit my credit card for the total amount indicated above. Signature:__________________________________________________________________ Date: Please help us to provide you with speedy customer service; review your application one more time to make sure you have submitted all the required documents and correct payment amount. Thank you for applying for a Practical or Registered Nurse License with the Wyoming State Board of Nursing! We look forward to having you join us in fulfilling our mission: To serve and safeguard the people of Wyoming through the regulation of nursing education and practice. RETURN YOUR COMPLETE APPLICATION AND PAYMENT PAYABLE TO: Wyoming State Board of Nursing 130 Hobbs Avenue – Suite B Cheyenne, WY 82002 Page 4 of 9 RN/LPN Examination 4/11/2013
Complete this application ONLY if you are seeking licensure by EXAMINATION I am applying for a graduate temporary permit and have included 1) a complete application 2) payment and 3) have requested the DON send a notarized letter of program completion or official transcripts. Graduate temporary permits are good for 90 days from date of issue and will be issued upon processing unless a specific start date is provided. Graduate temporary permits shall become invalid if you fail to pass the NCLEX-RN or NCLEX-PN. Requested start date: ________________________________________ 1) Check the box that best describes you: Registered Nurse Licensure by Examination Licensed Practical Nurse by Examination I require testing accommodations and am providing the required documentation: No Yes 2) Personal Information: Social Security Number___________________________ Date of Birth_________________________ Male/Female___ Last Name_________________ First Name_________________ Middle Name__________ Maiden Name___________ Mailing Address________________________________________ City__________________ State____ Zip_________ Phone_______________________ Work Phone____________________ E-mail address_______________________ 3) Lawful Presence: (Described in instructions, page 1) You must provide evidence of your lawful presence in the U.S. to be granted professional licensure. Please provide a copy of your Social Security Card and one of the following: U.S. Birth Certificate U.S. Passport Certificate of Naturalization Certificate of Citizenship INS Form I-551 (commonly known as a “green card/visa”) Exp. Date: __________ Driver’s License Other documentation that shows lawful admittance into the United States 4) Check your highest NON-NURSING education __High School Diploma __Associate Degree __Baccalaureate Degree __Master’s Degree __Doctorate Degree 5) Name and Location of Nursing Education Program completed for your RN or LPN: Name of nursing program:____________________________________ City and State:____________________________ Date Enrolled_________________ (month and year) Date Completed_______________ Degree Earned:________________________ (month and year) Name and location of any additional nursing education:_____________________________________________________ City _________________________ State:______ Date Enrolled_____________ Date Completed___________________ Degree Earned:___________________________________ Did you receive funding for your RN/LPN education program from Wyoming by Workforce Services, a healthcare facility, federal grant or similar funding program? Yes No Page 3 of 9 RN/LPN Examination 4/11/2013
Page 1 and 2: APPLICATION FOR WYOMING REGISTERED
Page 3: What you need to get started: (Chec
Page 7 and 8: Applicant Name: ___________________
Page 9: Applicatant Name: _________________

RN LPN Exam Application - Wyoming State Board of Nursing

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