Reinstatement Application - Wyoming State Board of Nursing

What you need to get started: (Check off items as you complete them)___ A form of payment WSBN accepts (money order, cashier’s check, VISA, MasterCard or Discover, page 3).___ A copy of documentation that you meet at least one (1) of the required continued competencies options (page 4).____ A copy of documentation of meeting requirements of a prior WSBN order, if applicable (such as particularrequirements indicated for reinstatement, compliance with conditions or other terms).____ A copy of documentation of meeting the “good cause” requirement (such as any information that supports yourreturn to nursing or nursing assistant practice; for example: professional letters of recommendations or support, additionalactivities outside of requirements of the prior WSBN order, or opportunities to gain employment if reinstated).Additional submissions (if requested)____ Fingerprint cards. If you have disclosed a pending criminal matter or a criminal conviction since your license wassurrendered, conditioned, revoked or suspended, the WSBN may request that you submit to a criminal background checkbefore we can issue a license or certificate. If a criminal background check is requested you will be contacted about thesubmission of fingerprint cards and applicable fees. Fingerprint cards will then be sent to you. Once you receive thefingerprint cards, provide completed fingerprint cards, following the instructions for chain of custody, and return toWSBN. You must return the completed fingerprint cards, applicable fee, and WSBN must receive the backgroundcheck report from the reporting agency before your license or certificate will be issued.If you would like your fingerprint cards mailed to a different address than what is listed on your application, pleaseprovide a self-addressed envelope (8” X 11”)._____ Mental/Physical Examination. If you have disclosed a mental or physical disability, or the existence of anaddiction (including treatment) since your license was surrendered, conditioned, revoked or suspended, the WSBN mayrequest that you submit to a biophysical, psychological, psychiatric, substance abuse, anger management, or competencyevaluation to confirm your ability to provide safe practice to the public before we can issue a license or certificate. Youwill be responsible for the costs of such evaluations.Changes in contact informationPlease advise us of any changes in the address, telephone or email information you submit with your application. If youdo not do so, it may delay the issuance of your license or certificate.Page 2 of 7APPLICATION FOR REINSTATEMENT of WYOMING NURSE LICENSURE or CERTIFICATION