RN LPN Re-Exam - Wyoming State Board of Nursing

APPLICATION FORRN/LPN LICENSUREByRE-EXAMINATION*All licenses expire December 31 of every EVEN year*NO REFUNDS. NO PERSONAL CHECKS OR CASH. Fees are subject to change. All licenses expire by December 31 of everyEVEN year.PAYMENT MUST ACCOMPANY APPLICATION. If a third party is paying separately, include an explanation.INCOMPLETE APPLICATION: Application must include all required information or it is considered incomplete. Incompleteapplications will be held for one (1) year from the date received. After one (1) year, application, fingerprint cards and fees must beresubmitted.WYOMING HAS A MANDATORY LICENSURE LAW. Individuals wishing to practice nursing in Wyoming must have a temporarypermit or license to practice. Re-examination applicants are not eligible for a temporary permit.MANDATORY CRIMINAL BACKGROUND CHECK (CBC): If it has been more than one (1) year since fingerprint cards wereoriginally submitted to the WSBN, you must submit new cards and pay the fee for a new CBC.I AM APPLYING FOR:REGISTERED PROFESSIONAL NURSE LICENSURELICENSED PRACTICAL NURSE LICENSUREPersonal 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_______________________LIST EMPLOYMENT HISTORY FOR THE PERIOD BETWEEN NOW AND YOUR LAST APPLICATION:Give complete name and address, including city, state, and zip code for all employers listed. Attach a separate sheet ifnecessary.Include dates of unemployment, travel, school, homemaker, etc. Do not leave any period of time unaccounted for or theapplication will be returned to you for completion.1. BEGINNING DATE__________________________________ END DATE_______________________________ HOURS PER WEEK___________(Month and Year)(Month and Year)EMPLOYER NAME___________________________________________________________________ PHONE_______________________________ADDRESS________________________________________________ CITY____________________________ STATE__________ ZIP____________POSITION___________________________________________________ SUPERVISOR_________________________________________________2. BEGINNING DATE__________________________________ END DATE_______________________________ HOURS PER WEEK___________(Month and Year)(Month and Year)EMPLOYER NAME___________________________________________________________________ PHONE_______________________________ADDRESS________________________________________________ CITY____________________________ STATE__________ ZIP____________POSITION___________________________________________________ SUPERVISOR_________________________________________________Page 1 of 3RN/LPN Re-Exam Application 4/11/2013

Applicant Name___________________________ALL QUESTIONS MUST BE ANSWERED BY THE APPLICANT. If you fail to answer each and every question andprovide necessary documentation for any “Yes” answer the processing of your application will be significantly delayed.Your application is INCOMPLETE until all required documentation is received. Your personal statement must include 1)month and year of the incident; 2) full description of the incident; 3) legal/court action taken against you; 4) treatment andoutcome of treatment if applicable (i.e. mental health, substance abuse, etc.); and 5) the date of your statement and yourlegible signature. Since your last application:1. Has any disciplinary action been taken or is pending (i.e. open investigation) against you from a LICENSINGAUTHORITY? No Yes If “YES”, provide: • Personal Statement •Documentation of disciplinary action2. Have you ever been investigated or charged with ABUSE, NEGLECT OR MISAPPROPRIATION OFPROPERTY? No Yes If “YES”, provide: •Personal Statement • Documentation of disciplinary action3. Has your application for examination or licensure ever been DENIED BY A LICENSING AUTHORITY? No Yes If “YES”, provide: •Personal Statement •Documentation of the denial action4. Do you have a physical or mental disability which renders you unable to perform nursing services or duties withreasonable skill and safety and which may endanger the health and safety of persons under your care? No Yes If “YES”, provide: •Personal Statement • Progress report from counselor/physician• Discharge summary/aftercare plan from hospitalizations (IF you were hospitalized)5. Are you now or have you in the past five (5) years been addicted to any controlled substance, a regular user ofany controlled substance with or without a prescription, or habitually intemperate in the use of intoxicating liquor? No Yes If “YES”, provide: •Personal Statement • Progress report from counselor/physician• Discharge summary/aftercare plan from hospitalizations (IF you were hospitalized)6. Have you been terminated or permitted to resign in lieu of termination from a nursing or other health care positionbecause of your use of alcohol or use of any controlled substance, habit-forming drug, prescription medication, ordrugs having similar effects? No Yes If “YES”, provide: •Personal Statement • Progress report from counselor/physician• Discharge summary/aftercare plan from hospitalizations (IF you were hospitalized)7. Have you ever been convicted, pled guilty to, pled nolo contendere to, or have charges pending against you forany crime including felonies, misdemeanors, municipal ordinances, and/or any Uniform Code of Military Justiceviolations, including driving under the influence of any intoxicating substance? Do not include non-movingtraffic violations or moving violations which did not involve alcohol or substance impairment. No YesIf “YES”, provide a Personal Statement and court documents including:•Information Sheet or Ticket•Judgment and Sentencing•Proof of compliance with the following (if applicable):o Court Order o Fines Paido Probation Completion o Classes Attendedo Evaluation Completed and Subsequent Action on that EvaluationSIGNATURE REQUIRED:I certify under penalty of perjury and subject to the provisions of W.S. 6-5-303 and its penalties, that I have notknowingly submitted false or misleading information to the Wyoming State Board of Nursing on any applicationfor licensure or temporary permit. I understand the WSBN reserves the right to verify any information in thisapplication.Applicant’s Signature: ________________________________________________________Date: _____________Page 2 of 3RN/LPN Re-Exam Application 9/7/12