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In the intricate landscape of healthcare licensure, the New York Nurse 1 form exists as a pivotal document, ensuring that candidates aspiring to enter the nursing profession in New York State do so with the requisite credentials and integrity. Crafted by the University of the State of New York and the State Education Department, this comprehensive form serves as the initial step for applicants seeking licensure either as Registered Professional Nurses or Licensed Practical Nurses. The form, requiring a meticulous completion process and a non-refundable fee, delves into various critical areas including personal identification, educational background, legal declarations, and compliance with state-imposed obligations such as child support and infection control training. It insists on uniformity in the applicant’s name across all related documents to avoid testing and licensure delays, thereby emphasizing the state’s commitment to precision. Furthermore, by mandating detailed disclosures regarding past criminal, educational, and professional history, it underscores a thorough vetting process aimed at maintaining high standards within the nursing profession. Applicants are also required to navigate through questions regarding citizenship and immigration status, aligning with federal and state regulations. In essence, the New York Nurse 1 form embodies a rigorous gateway to professional nursing practice, reflecting the importance of integrity, competence, and accountability in safeguarding public health and welfare within the Empire State.

New York Nurse 1 Sample

The University of the State of New York

 

 

 

 

 

 

 

This Area For Department Use Only

 

 

 

 

 

 

 

 

 

 

 

 

The State Education Department

 

 

Nurse Form 1

 

 

 

 

 

 

Office of the Professions

 

 

 

 

 

 

 

 

 

Application for Licensure

 

 

 

 

 

Division of Professional Licensing Services

 

 

 

 

 

 

 

 

www.op.nysed.gov

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All applicants for licensure must complete this form and submit it with the appropriate fee ($143) directly to

 

 

 

 

 

the Office of the Professions at the address at the end of this form. The $143 fee is the total of the application

 

 

 

 

 

fee ($70) plus the fee for your first registration period ($73). The application portion of the fee is not refundable.

 

 

 

 

 

You must answer all questions in ink (pen or printer) and provide all information requested unless otherwise

 

 

 

 

 

indicated. Failure to complete all required parts of the application will delay its review. You must sign and date

 

 

 

 

 

the Affidavit on this form in the presence of a Notary Public.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check what you are applying for (check one):

 

 

 

 

 

 

 

 

 

 

 

 

 

Registered Professional Nurse

22

$143

ER

 

 

Licensed Practical Nurse

 

10

$143

ER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The name listed on your application for licensure, the name on your photo identification, and the name listed on your NCLEX application must ALL match EXACTLY. If your name does not exactly match in all instances it will delay your authorization to test (ATT), you may not be allowed to take the exam at your scheduled time and you may incur additional fees to test.

1.

Social Security Number

 

 

 

 

 

 

 

 

2. Birth Date

Month

 

 

 

 

 

Day

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Leave this blank if you do not have a U.S. Social Security Number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Print Name

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Telephone/Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home or

 

 

Business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Licensee business address, phone and email address are public information. Failure to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

indicate business or home on this form for each item will deem it public information.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Mailing Address

Home or

 

 

 

Business

 

 

 

 

 

Area Code

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(You must notify the Department promptly of any address or name changes)

 

 

 

 

Email Address (please print clearly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Line 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home or

 

 

Business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Line 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Line 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. New York State DMV ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Driver or Non-Driver ID)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Leave this blank if you do not have a

 

 

 

 

 

Country/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New York State DMV ID Number)

 

 

 

 

 

Province

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Do you have a CGFNS record?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If "yes", enter your CGFNS Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Name as it appears on degree or other credentials (if different from above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Have you ever applied for New York State licensure in any profession?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

If "yes", in what profession(s)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Are criminal charges pending against you in any court?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Are charges pending against you in any jurisdiction for any sort of professional misconduct?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Has any hospital, licensed facility or clinical laboratory restricted or terminated your professional training,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association

 

 

 

 

 

 

 

 

 

 

 

 

to avoid imposition of such measures?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If you answer "Yes" to any questions numbered 10-14, submit a letter giving a complete detailed explanation. Include copies of any court records including a Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. In answering these questions, consider whether, pursuant to Executive Law § 296(16), you are required to report any arrests, criminal accusations, or dispositions of such arrests or criminal accusations. If the court can no longer provide documentation, you must request, from the court, a letter stating why they cannot provide the documents. While your application is pending, you must notify the Division of Professional Licensing Services if the answers to any of these questions have changed.

Nurse Form 1, Page 1 of 4, Revised 11/19

15. Do you now hold, or have you ever held, a license or certificate to practice any profession in any state or jurisdiction?

 

Yes

 

 

No

If yes, list each license/certificate, state or jurisdiction and provide appropriate information in the columns below. A Form 3 or Nursys

 

license verification (for states reporting to Nursys) must be submitted for each professional 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

License/Certificate

Issued

Number

 

 

Limitations

on License/Certificate

16.You must complete all information for all schools/colleges/universities attended or your application will be considered incomplete. Note: If you are applying for licensure as a licensed practical nurse and you did not graduate from a New York State approved nursing program, you must submit a copy of your high school or secondary school diploma or transcript in the original language with your Form 1. If you were educated outside the U.S. or a Canadian province other than Quebec with a BN, BSN or BScN after

January 1, 2015), submit a copy of your nursing diploma in the original language.

Elementary or Primary School - Please complete the section below with details about your elementary or primary school. Attach additional sheets if you attended multiple schools. Any missing information will be considered an incomplete application.

Name of School

City

State/Province

 

 

 

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of years attended

Attendance from

 

 

to

 

 

 

 

Completion date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

yr.

 

mo.

 

yr.

 

 

 

mo.

 

yr.

 

High School/Secondary School or Equivalency Diploma Issuer - Please complete the section below with details about your high school/secondary school or equivalency diploma issuer. Attach additional sheets if you attended multiple schools. Any missing information will be considered an incomplete application.

Name of School

City

State/Province

 

 

 

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of years attended

Attendance from

 

 

to

 

 

 

 

Completion date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

yr.

 

mo.

 

yr.

 

 

 

mo.

 

yr.

 

Nurse Program - Please complete the section below with details about your nursing program. Attach additional sheets if you attended multiple programs. Any missing information will be considered an incomplete application.

Name of School

City

 

State/Province

 

 

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Major/Concentration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of years attended

 

Attendance from

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

yr.

 

mo.

 

yr.

 

 

 

 

Title of Degree/Diploma/Certificate awarded (in original language)

 

 

 

 

 

 

 

 

 

Or

 

Still in progress

 

 

 

 

 

 

 

 

 

 

Date Degree/Diploma/Certificate awarded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

yr.

 

 

 

 

 

 

 

 

 

 

 

 

 

Postsecondary Education - Please complete the section below with details about your postsecondary education. Attach additional sheets if you attended multiple schools. Any missing information will be considered an incomplete application.

Name of School

City

 

State/Province

 

 

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Major/Concentration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of years attended

 

Attendance from

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

yr.

 

mo.

 

yr.

 

 

 

 

Title of Degree/Diploma/Certificate awarded (in original language)

 

 

 

 

 

 

 

 

 

Or

 

Still in progress

 

 

 

 

 

 

 

 

 

 

Date Degree/Diploma/Certificate awarded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

yr.

 

 

 

 

 

 

 

 

 

 

 

 

 

Nurse Form 1, Page 2 of 4, Revised 11/19

17.If you have ever taken the SBTP, NCLEX, or a state-constructed examination for licensure as either a Registered Professional Nurse or a Licensed Practical Nurse in the United States or its territories (except New York State), complete the following:

State or Territory*

 

Profession

 

Exam Name

 

Exam Date

 

If Granted, License No.

 

 

 

 

 

 

 

 

 

State or Territory*

 

Profession

 

Exam Name

 

Exam Date

 

If Granted, License No.

 

 

 

 

 

 

 

 

 

State or Territory*

 

Profession

 

Exam Name

 

Exam Date

 

If Granted, License No.

 

 

 

 

 

 

 

 

 

State or Territory*

 

Profession

 

Exam Name

 

Exam Date

 

If Granted, License No.

*If you took the NCLEX or SBTP Examination, send Form 3 to the state in which you passed the licensing examination or request verification from Nursys.

18.Child Support Obligation

Everyone applying for a professional license, permit, or registration, or any renewal thereof, must certify 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 3-503

19.Citizenship/Immigration Status

Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses, registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner’s regulation, you must complete this section of this form and check the appropriate box below which indicates your citizenship/immigration status.

I am:

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 am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or similar relief from deportation. Please specify

J. I do not reside in the United States.

If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States 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 1-800-375-5283,

OR VISIT THE USCIS WEBSITE.

Nurse Form 1, Page 3 of 4, Revised 11/19

20. Child Abuse Identification and Reporting Coursework Requirement - RN Applicants Only (check one)

I graduated from a NYS registered program and completed the child abuse identification training as part of my studies.

I completed the child abuse coursework and have enclosed a certificate of completion from an approved provider

I completed the child abuse coursework online and the approved provider will report that to you electronically. I am filing for an exemption to the requirement and have enclosed the Certification of Exemption (Form 1CE).

21. Infection Control Training Requirement (check one)

I graduated from a NYS registered licensure qualifying program within the last four years and completed the infection control training during my studies.

I completed the infection control training within the last four years and have enclosed a certificate of completion from an approved provider.

I completed the infection control training online within the last four years and the approved provider will report that to you electronically.

I am filing for an exemption to the requirement and have enclosed an Attestation of Infection Control Training (Form 1IC).

22. Reasonable Testing Accommodations for Individuals with Disabilities. (check if applicable)

I have been diagnosed as having a disability and require special testing accommodations and am submitting the Request for Reasonable Testing Accommodations form. I understand that I will not be able to test until I submit the appropriate documentation and am approved to test with accommodations. (Visit the Office of the Professions' website for information on obtaining the form.)

23.Gender and Ethnicity (This item is optional)

Information on gender and ethnicity is sought solely to allow the New York State 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

 

 

 

 

 

 

24. 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

25.Affidavit with Acknowledgement (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. This form must be signed and dated in the presence of a Notary Public.

Applicant's Signature

 

 

 

 

 

 

 

Date

Notary

 

 

 

 

 

 

 

 

 

State of

 

 

 

 

County of

 

 

 

 

On the

 

day of

 

 

in the year

 

 

before me, the above signed,

 

 

 

 

 

 

 

 

 

 

 

personally appeared

 

 

 

 

 

 

, personally known to me or proved to me on the basis

 

 

 

 

 

Applicant name

 

 

 

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's Signature

Notary Stamp

Notary ID number

Expiration Date

If you are submitting an initial Form 1, mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201, U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.

If the Department has requested an updated Form 1, mail this form to: New York State Education Department, Office of the Professions, Nurse Unit, 89 Washington Avenue, Albany, NY 12234-1000. NO FEE IS NEEDED FOR THIS OPTION.

Nurse Form 1, Page 4 of 4, Revised 11/19

⇩ New York Nurse 1

File Overview

Fact Detail
Form Name and Purpose Nurse Form 1 is an application for licensure for nurses in New York, used to apply for licensure as either a Registered Professional Nurse or a Licensed Practical Nurse.
Submission and Fee The form, accompanied by a $143 fee, must be submitted directly to the Office of the Professions at the New York State Education Department. This fee includes both the application fee ($70) and the fee for the first registration period ($73).
Application Requirements All questions must be answered in ink and all requested information provided. Failure to complete the form fully will delay its review. The application must be signed and dated in the presence of a Notary Public.
Consistency in Personal Information The name on the licensure application, photo identification, and NCLEX application must match exactly. Discrepancies can delay testing authorization and may incur additional fees.
Governing Law(s) The form is regulated by the University of the State of New York and the State Education Department, adhering to New York laws governing professional licensing.
Additional Requirements for Foreign Educated Nurses Nurses educated outside the U.S. or Canadian provinces (other than Quebec) after January 1, 2015, must submit a copy of their nursing diploma in the original language along with their Form 1 application.

New York Nurse 1: Usage Guidelines

Filling out the New York Nurse 1 form is a critical step in the journey towards becoming a licensed nurse in New York State. It's the beginning of a process that requires attention to detail and accuracy. The information provided will be used to assess qualifications and eligibility for licensure. Following the steps below carefully will help ensure that the application is completed correctly and efficiently, avoiding any delays.

  1. Start by downloading the Nurse Form 1 from the New York State Education Department's website if you haven't done so already.
  2. Fill out the required fee of $143 for the application. This amount is a combination of the application fee ($70) and the fee for the first registration period ($73). Remember, the application fee is non-refurable.
  3. Choose the type of licensure you are applying for: "Registered Professional Nurse" or "Licensed Practical Nurse" by checking the appropriate box.
  4. Enter your Social Security Number (SSN) in the designated field. If you do not have a U.S. SSN, leave this section blank.
  5. Complete your personal information, starting with your birth date, followed by your name as it should appear on the license. Ensure this matches the name on your photo ID and NCLEX application to avoid delays.
  6. Provide a valid telephone/email address and indicate whether it's your home or business address. This information will be publicly available unless specified otherwise.
  7. For those who have a New York State DMV ID number (Driver or Non-Driver ID), enter it in the designated field. If you don't have one, leave it blank.
  8. Answer the question about having a CGFNS record and provide the CGFNS number if applicable.
  9. Disclose if you've previously applied for New York State licensure in any profession, and if so, specify the profession(s).
  10. Respond to questions about past criminal charges, current charges, disciplinary actions, or professional misconduct allegations meticulously. If you answer "Yes" to any, a detailed explanation and relevant court documents are required.
  11. Detail any past or current licenses or certificates you hold, including state or jurisdiction, license number, and any limitations. If you've been licensed in another state, a Form 3 or Nursys license verification will be necessary.
  12. Document your educational history accurately, including elementary or primary school, high school/secondary school, nursing program, and any postsecondary education. Attach additional sheets if more space is needed.
  13. If you've taken licensure exams in other states or territories, provide details including the state, profession, exam name, date, and if a license was granted.
  14. Complete the Child Support Obligation section honestly, checking the relevant boxes that apply to your situation.
  15. Indicate your Citizenship/Immigration Status by selecting the appropriate box that represents your status and provide your USCIS number if applicable.
  16. For RN applicants, specify how you've met the Child Abuse Identification and Reporting Coursework Requirement. Check the appropriate box.
  17. Complete the Infection Control Training Requirement section by indicating your compliance through education or training.
  18. If applicable, request Reasonable Testing Accommodations due to a diagnosed disability.
  19. Optionally, provide Gender and Ethnicity information for statistical and research purposes.
  20. If agreeing, give permission for the New York State Education Department to release your examination results to your professional school by initialing the appropriate section.
  21. Under the Affidavit section, ensure the form is signed and dated in the presence of a Notary Public, who will also need to sign, date, and provide their stamp and ID number.
  22. Finally, mail the completed form along with the appropriate fee to the address provided at the end of the form. Remember to make the check or money order payable to the New York State Education Department.

Carefully reviewing and accurately completing each step will smooth the path towards licensure. Diligence now will pay off in making the process as quick and seamless as possible.

FAQ

  1. Who needs to complete the New York Nurse Form 1?

    All applicants seeking licensure as either a Registered Professional Nurse or a Licensed Practical Nurse in New York State must complete Nurse Form 1. This form is integral to the application process and serves as the main application for licensure, which the Office of the Professions within the State Education Department processes.

  2. What is the total fee for submitting Nurse Form 1, and is it refundable?

    The total fee for submitting Nurse Form 1 is $143, which comprises a $70 application fee and a $73 fee for the first registration period. It's critical to note that the application fee portion of this total is not refundable under any circumstances.

  3. What happens if my names do not match across my application, photo identification, and NCLEX application?

    If there is a discrepancy in the name listed across your application for licensure, your photo identification, and your NCLEX application, this can cause significant delays. It may prevent you from receiving authorization to test (ATT), possibly barring you from sitting for the exam at your scheduled time, and could incur additional fees to rectify the mismatch and reschedule testing.

  4. Is it required to report criminal history or disciplinary actions on Nurse Form 1?

    Yes, applicants must disclose any past criminal convictions, pending criminal charges, and any disciplinary actions taken against them by licensing or disciplinary authorities. Failure to report these accurately can affect the application's outcome and result in criminal prosecution for providing false or misleading information.

  5. How does one report previous education and examinations when applying?

    Applicants must meticulously document all schools, colleges, or universities attended, including providing details about their nursing program, degree awarded, and dates of attendance. For those who have previously taken licensure exams like the NCLEX or the SBTP in another state, proper documentation and verification through Form 3 or Nursys must be submitted unless the license was issued by the New York State Education Department.

  6. What are the requirements regarding compliance with child support obligations?

    Applicants for professional licensure, including nursing in New York State, must certify their compliance with child support obligations. Those not in compliance may see their licenses suspended or limited to a short-term issue to allow for compliance efforts. Falsifying statements regarding child support obligations is subject to legal penalties.

Common mistakes

Applying for licensure as a nurse in New York is a critical step in a nursing professional's career. However, the process can be complicated, and mistakes on the New York Nurse Form 1 can delay or even derail an application. Here are eight common mistakes applicants make when filling out this form:

  1. Not using black ink or a printer: The instructions specify that all questions must be answered in ink (pen or printer). Utilizing different colored inks or pencil may lead to processing delays or the necessity for resubmission.

  2. Inconsistent name matching: The name listed on the application for licensure, photo identification, and NCLEX application must match exactly. Any discrepancies in spelling or order can delay the authorization to test and potentially incur additional fees.

  3. Omitting a Social Security or DMV ID Number: If available, these numbers must be included. For applicants without a U.S. Social Security Number or New York State DMV ID, leaving these fields blank as instructed is crucial to avoid confusion.

  4. Failing to specify contact information correctly: The form requires specifying whether an address or phone number is a home or business one. Failure to do so will automatically deem the information public, which might not be the applicant's intent.

  5. Not providing complete educational history: All information for all schools, colleges, or universities attended must be completed. Leaving sections incomplete is a common oversight that leads to an incomplete application.

  6. Forgetting to include supporting documents for past convictions or professional discipline: Answering "Yes" to questions about past legal or professional issues requires submitting detailed explanations and supporting documents. Overlooking this requirement can significantly delay the process.

  7. Incorrectly handling the Child Support Obligation section: This section must be filled out accurately, reflecting the applicant's current status regarding child support obligations. False statements here are punishable under law.

  8. Neglecting citizenship or immigration status: Failing to accurately complete the citizenship/immigration status section can result in processing delays. This information is paramount in determining eligibility for licensure under federal law.

Avoiding these pitfalls can smooth the path to receiving licensure. It's also valuable to regularly check the status of an application and update any information as necessary to ensure a timely review process. Remember, the key to a successful application is attention to detail and strict adherence to the form's instructions.

Documents used along the form

When applying for licensure as a nurse in New York State with the Nurse Form 1, applicants often need to complement their submission with various other forms and documents to satisfy the comprehensive requirements set by the New York State Education Department. These additional documents ensure the application is thoroughly reviewed and processed without delay, addressing different aspects of the applicant's background, education, and qualifications.

  • Child Abuse Identification and Reporting Coursework Requirement (RN Applicants Only): This document certifies that the applicant has completed the necessary training in identifying and reporting child abuse, a requirement for registered professional nurses in New York.
  • Infection Control Training Requirement: Similar to the child abuse identification coursework, this document certifies that the applicant has completed training in infection control practices, a mandatory requirement for all healthcare professionals in New York.
  • Certificate of Professional Education: This document provides proof of the applicant's completion of a nursing program. It must be an official transcript or diploma from the educational institution.
  • Verification of Out-of-State Licensure (Form 3): If the applicant holds or has held a nursing license in another jurisdiction, they must submit Form 3 for verification of licensure from each state or territory where they have been licensed.
  • Criminal History Record: Applicants must disclose any criminal history as part of their application. If applicable, they should include a Certificate of Disposition or similar documentation for each incident.
  • Request for Reasonable Testing Accommodations form: Applicants with disabilities may request accommodations for taking the licensure examination. This form includes details about the nature of the disability and the specific accommodations requested.
  • Child Support Obligation Form: All applicants must affirm their status regarding any child support obligations, indicating compliance or detailing the circumstances of their situation.
  • Citizenship/Immigration Status Verification: As required by federal law and the Regulations of the Commissioner of Education, applicants must provide documentation verifying their citizenship status or legal presence in the United States.
  • Affidavit of Verification: This notarized document is part of Nurse Form 1, wherein the applicant affirms that all information provided in the application and supporting documents is true and accurate.

Together with Nurse Form 1, these documents provide the New York State Education Department with a comprehensive profile of the applicant, ensuring that all licensure candidates meet the high standards required for professional practice in New York. Applicants are advised to carefully read the instructions for each form and document to ensure complete and accurate submissions.

Similar forms

The New York Nurse 1 form shares similarities with a Medical License Application used by doctors seeking licensure to practice medicine. Both documents require detailed personal information, educational background, and a comprehensive history of any legal or disciplinary actions taken against the applicant. They also include sections for examining criminal history, professional experience, and verification of licensure in other states or jurisdictions. Applicants must disclose any past or pending legal issues that could affect their licensure status, similar to the Nurse Form 1.

A Dental License Application is another document that parallels the New York Nurse 1 form, particularly in its structure and the necessity for applicants to provide exhaustive educational histories and professional experiences. Applicants are required to demonstrate their eligibility through past educational achievements and by providing a record of any board examinations taken, similar to the nursing licensure process. This document also mandates the disclosure of any criminal or professional disciplinary actions, closely mirroring the Nurse Form 1's requirements.

Pharmacy License Applications bear resemblance to the New York Nurse 1 form as well, especially in the aspects of requiring detailed personal data, educational background, and a history of any disciplinary or criminal actions. Both forms ask for information about past licensures and include questions regarding the applicant's criminal and professional discipline history. There's a specific focus on ensuring the applicant meets all professional and ethical standards required for practice in their respective fields.

Professional Engineer License Applications share similarities with the New York Nurse 1 form in terms of the rigorous documentation of educational qualifications and professional experiences. These applications both scrutinize the applicant's background for any legal or disciplinary issues that could impact their professional practice. They also require information on any examinations taken that are relevant to their field, ensuring that applicants meet the high standards expected in their professional community.

Teacher Certification Applications, while differing in field, share the New York Nurse 1 form's emphasis on thorough background checks, educational history, and certification examinations. Both documents include questions about previous licensures, certifications, or any disciplinary actions that could affect the applicant's eligibility. The focus on ethical conduct and professional integrity is paramount in both forms, underscoring the responsibility each profession carries towards public service.

Physical Therapy License Applications, similar to the New York Nurse 1 form, require detailed information regarding the applicant's education, clinical experiences, and any licensure examinations completed. Both forms necessitate disclosures about criminal history and any past disciplinary actions within their professions. This parallel emphasizes the healthcare industry's focus on maintaining high standards of practice and ensuring that practitioners are fit to provide care.

Social Work License Applications also mirror the New York Nurse 1 form in several respects, including the need for educational history, examination records, and a clean disciplinary record. These applications delve into the applicant's background to a similar degree, requiring information on any legal issues that might impact their ability to serve in a trust-based profession. The disclosure requirements reflect the shared goal of protecting public welfare and ensuring the integrity of the professional community.

In conclusion, the New York Nurse 1 form closely aligns with various professional licensure applications across healthcare and other regulated fields. These documents collectively aim to vet candidates rigorously, ensuring they meet the required educational, legal, and ethical standards to practice their professions, thereby safeguarding public interest and upholding the prestige and integrity of the profession.

Dos and Don'ts

When applying for licensure with the New York Nurse 1 form, certain steps and precautions ensure a smooth application process. Below is a list of do's and don'ts to consider:

  • Do use ink (pen or printer) to fill out the form to ensure the information is legible and permanent.
  • Do make sure to sign and date the Affidavit section in the presence of a Notary Public, as this validates your application.
  • Do check the accuracy of the information provided, especially your name, as it must match across your application for licensure, photo identification, and NCLEX application.
  • Do pay the application fee with a check or money order made payable to the New York State Education Department; cash is not accepted.
  • Do provide complete and accurate answers to all questions; incomplete answers may result in the delay of your application.
  • Don't leave any fields blank unless specifically stated. For example, your Social Security Number or New York State DMV ID Number (if you do not possess such numbers, it's mentioned to leave the field blank).
  • Don't forget to keep a copy of your application and all documents submitted for your own records.
  • Don't fail to report any changes in your information, such as address or name changes, while your application is pending.
  • Don't overlook the need to submit additional forms or documents, such as Form 3 for license/certificate verification or proof of child support obligation status.

Following these guidelines can lead to a smoother licensure application process, ensuring that all necessary information is correctly presented the first time.

Misconceptions

When applying for licensure as a nurse in New York State, some applicants have misconceptions about the New York Nurse Form 1. Let's clarify six common misconceptions to guide applicants correctly.

  • Misconception 1: The application fee is refundable if I change my mind. The form clearly states that the application portion of the fee, which is $70 out of the total $143, is not refundable. Applicants need to be certain before submitting their application and fee.
  • Misconception 2: It’s okay if my name doesn’t match on all documents. The form requires that the name listed on your application, photo ID, and NCLEX application must all match exactly. Any discrepancies can delay your authorization to test or lead to additional fees.
  • Misconception 3: I don’t need to worry about updating my address. Applicants must promptly notify the Department of any address or name changes. Failure to do so could result in missed communications vital for your licensure process.
  • Misconception 4: Criminal history will automatically disqualify me. While disclosing a criminal history is required, it does not automatically disqualify an applicant. Each case is considered individually, and applicants must provide detailed explanations and court records for review.
  • Misconception 5: My education details aren’t crucial if I have the necessary credits. Every section regarding educational history must be completed. This includes information on high school or secondary school, nursing program, and any postsecondary education. Incomplete education details can render an application incomplete.
  • Misconception 6: If I’ve taken the NCLEX, I don’t need to provide examination details. Even if you've taken the NCLEX or any other nursing licensure examination, the form requires detailed information about the exam(s) taken, including the state, exam name, and date. This is crucial for verifying your licensure status and examination history.

Understanding the requirements and expectations of the New York Nurse Form 1 is crucial for all applicants. By clarifying these common misconceptions, applicants can improve their chance of a smooth application process for their nursing licensure in New York State.

Key takeaways

Filling out and using the New York Nurse 1 form is a vital step for individuals seeking licensure in nursing within the state. To ensure the process is as smooth as possible, here are eight key takeaways to keep in mind:

  • Applicants must submit this form alongside a fee of $143, which covers both the application fee and the first registration period. It's crucial to note that the application portion of this fee is not refundable.
  • Every question on the form needs to be answered with a pen or printer; incomplete forms can lead to delays in the review process. Therefore, providing all requested information is paramount.
  • The exact match of the applicant's name across their application for licensure, photo identification, and NCLEX application is essential to avoid delays and additional fees.
  • An affidavit section requires signing and dating in the presence of a Notary Public, emphasizing the importance of formal verification of the applicant's identity and claims.
  • Disclosure of any criminal history and professional disciplinary actions is mandatory, with a requirement to submit detailed explanations and documentation for any "Yes" responses to relevant questions.
  • Educational history, including details about elementary, secondary, and nursing education, must be thoroughly documented. Missing information can render the application incomplete.
  • Certain sections specifically address compliance with child support obligations and citizenship/immigration status, underlining the necessity to comply with state and federal laws.
  • Special sections are devoted to mandatory coursework in Child Abuse Identification and Reporting, and Infection Control Training, highlighting specific educational requirements for nursing licensure in New York.

Understanding and carefully following these guidelines when completing the New York Nurse 1 form can significantly facilitate the licensure process, ensuring that applicants meet all regulatory requirements for a career in nursing within the state.

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