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Embarking on the journey to become a licensed nurse in New York State is a significant step that requires attention to detail and adherence to the processes outlined by the New York State Education Department. The Nurse Form 1 is a crucial part of this process, acting as the application for licensure that prospective nurses must complete and submit along with a specified fee. This comprehensive form requests detailed information about the applicant, including personal information, educational background, and professional history. It also inquires about the applicant's criminal history, if any, and their compliance with child support obligations, among other things. Applicants are required to provide accurate responses to all questions and to submit the form with the necessary fee directly to the Office of the Professions. Failure to complete the form thoroughly and accurately can result in delays in the review process or even denial of the licensure application. Moreover, this form serves as a testament to the applicant's commitment to entering the nursing profession, reinforcing the importance of integrity and honesty right from the get-go. With sections that cover educational qualifications, past examination attempts, and legal attestations, the Nurse Form 1 is designed to ensure that only qualified and eligible individuals are granted the privilege to practice nursing in the state of New York.

Nurse 1Nys Sample

The University of the State of New York

 

 

 

 

 

 

 

This Area For Department Use Only

 

 

Nurse Form 1

 

 

 

 

 

The State Education Department

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

*New York State General Obligations Law, section 3-503

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.

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

⇩ Nurse 1Nys

File Overview

Fact Name Description
Form Purpose The Nurse 1 Form is an application for licensure in the state of New York for Registered Professional Nurses and Licensed Practical Nurses.
Application Fee Applicants must submit a total fee of $143, which includes the application fee ($70) and the fee for the first registration period ($73).
Non-refundable Fee The application portion of the fee, $70, is not refundable under any circumstances.
Notarization Required Applicants must sign and date the Affidavit on the form in the presence of a Notary Public.
Consistency in Identification The name listed on the application, photo identification, and NCLEX application must match exactly to avoid delays or additional fees.
Documentation for Criminal History Applicants answering "Yes" to questions about criminal history or professional disciplinary actions must submit detailed explanations and relevant court records.

Nurse 1Nys: Usage Guidelines

Filling out the Nurse 1NYS form is an important step toward obtaining your nursing license in New York State. Completing this form accurately and thoroughly is crucial to ensure a smooth process. Whether you're applying to be a Registered Professional Nurse or a Licensed Practical Nurse, understanding how to fill out this form properly is the first step on your pathway to licensure. Let's walk through the required steps to complete the Nurse 1NYS form.

  1. Choose Your Application Category: Check the appropriate box to indicate whether you are applying for Registered Professional Nurse or Licensed Practical Nurse licensure.
  2. Personal Information: Begin by providing your Social Security Number, Birth Date (Month, Day, Year), and print your name as it appears on your identification documents.
  3. Contact Information: Fill in your telephone/email address, including a daytime phone number and email address. Remember, the address you provide will be public information unless specified otherwise.
  4. Mailing Address: Clearly indicate your mailing address, including Line 1, Line 2, City, State, ZIP Code, and Country/Province if applicable. If you do not have a New York State DMV ID number, leave this section blank.
  5. Educational Background: Specify if you have a CGFNS record and provide details regarding your education, including elementary (if applicable), secondary, and nursing education. For each school attended, list the school name, city, state/province, country, dates attended, and date of completion.
  6. Professional Licensure Information: Answer questions about any previous New York State licensure applications, criminal history, pending criminal charges, disciplinary actions, and professional training restrictions or terminations. Provide detailed explanations for any "Yes" responses.
  7. License Verification: If you have held a license or certificate in any profession in any state or jurisdiction, list each license/certificate, including the state or jurisdiction, date issued, and any limitations.
  8. Examinations: Detail any nursing licensure exams you've taken in the United States or its territories, excluding New York State. Provide the state or territory, profession, exam name, exam date, and license number if granted.
  9. Child Support Obligation: Certify your child support obligation status by selecting the appropriate option and providing additional information if applicable.
  10. Citizenship/Immigration Status: Indicate your citizenship or immigration status to ensure compliance with federal laws regarding professional licensure. Provide your alien registration number or control number if required.
  11. Training Requirements: Check the applicable box for child abuse identification and reporting coursework requirement (for RN applicants only) and infection training requirement. Indicate whether you are filing for an exemption if applicable.
  12. Special Testing Accommodations: If you require special testing accommodations due to a diagnosed disability, check the box and ensure you submit the Request for Reasonable Testing Accommodations form.
  13. Optional Information: You may choose to provide information regarding your gender and ethnicity for statistical purposes. This information has no bearing on your licensure qualification.
  14. Education Program Review: Grant permission for the New York State Education Department to release your examination results to your professional school for confidential program review purposes. Initial to confirm your consent.
  15. Affidavit: The application must be signed and dated in the presence of a Notary Public. Ensure the affidavit section is fully completed, including the notary's signature, stamp, ID number, and expiration date.
  16. Finally, review the entire form to ensure all information is accurate and complete. Submit the form along with the appropriate fee ($143) to the address specified at the end of the form.

After submitting your Nurse 1NYS form, the New York State Education Department will process your application. It's important to promptly notify the Department of any changes to your answers or personal information while your application is pending. Following these steps will help you navigate the initial phase of your nursing licensure procedure in New York State.

FAQ

  1. What is the Nurse 1Nys form, and who needs to complete it?

    The Nurse 1Nys form is an application for licensure managed by the New York State Education Department, Office of the Professions. It is required for individuals applying to become either a Registered Professional Nurse (RN) or a Licensed Practical Nurse (LPN) in New York State. This form needs to be completed and submitted with the appropriate fee by all applicants seeking licensure in these nursing professions.

  2. How much is the fee to submit the Nurse 1Nys form, and is it refundable?

    The total fee to submit the Nurse 1Nys form is $143, which includes a $70 application fee and a $73 fee for the first registration period. It is important to note that the application portion of the fee ($70) is non-refundable, regardless of the application's outcome.

  3. What information must be provided on the Nurse 1Nys form?

    Applicants must fill out the form in ink, answering all questions and providing all requested information. This includes personal details such as social security number, birth date, full name, contact information, and educational background. Additionally, applicants need to disclose any previous applications for licensure in any profession, criminal history, disciplinary actions in any profession, and any other licenses held.

  4. Why is it important that my name matches exactly on all documents?

    The name listed on your application for licensure, your photo identification, and your NCLEX application must match exactly. Consistency is crucial to avoid delays in your authorization to test (ATT), prevent being disallowed from taking your exam at the scheduled time, and avoid incurring additional fees. Exact matches are necessary to verify your identity and maintain accurate records.

  5. What happens if part of my application is incomplete?

    If any required part of the Nurse 1Nys application is incomplete, it will delay the review process. The Department relies on complete information to process applications efficiently. It is in the applicant's best interest to ensure that all sections of the form are filled out thoroughly and accurately.

  6. What should I do if I have a criminal record or have been disciplined in another profession?

    If you answer "Yes" to questions about criminal history or disciplinary actions in any profession, you must submit a detailed letter explaining the circumstances. This letter should be accompanied by court records, including a Certificate of Disposition for each action. It's vital to provide complete and honest explanations to facilitate the review of your application.

  7. Can I change my address or name after submitting the Nurse 1Nys form?

    Yes, you must promptly notify the Department of any address or name changes after submitting your application. Keeping your contact information current is important for receiving timely updates about your licensure status and ensuring that all correspondence reaches you.

  8. What are the requirements for education and exams listed on the Nurse 1Nys form?

    Applicants must provide detailed information about all schools, colleges, or universities attended. Specifically, licensed practical nurse applicants educated outside a New York State approved program must include their high school or secondary school diploma or its equivalent. Additionally, details about any professional licensure exams taken, including the NCLEX, must be included, especially if the exam was passed in another state or territory.

Common mistakes

Filling out the Nurse 1Nys form is a crucial step towards obtaining a nursing license in New York State. However, applicants often make mistakes that can delay or negatively impact their application process. Being aware of these common errors can help ensure a smoother path to licensure.

  1. One common mistake is not checking that the name listed on the Nurse 1Nys application, photo identification, and NCLEX application match exactly. Discrepancies among these documents can delay authorization to test and potentially result in additional fees.

  2. Applicants frequently overlook the instruction to answer all questions in ink. Filling out parts of the application in pencil or not ensuring all information is legible can cause delays in the review process.

  3. Another error is not being thorough with the educational history section. Failing to include all schools, colleges, or universities attended, along with the required dates and degrees, renders the application incomplete.

  4. Not signing and dating the affidavit in the presence of a notary public is an often-overlooked requirement. This oversight can invalidate the application, requiring the process to start over.

  5. Many applicants neglect to provide a detailed explanation and necessary documentation when answering "Yes" to questions about previous licensures, disciplinary actions, or criminal history. This omission can lead to requests for additional information and delays.

  6. Finally, incorrectly answering the child support obligation question by not checking one of the required statements under part B can halt the processing of the application. This section must be correctly completed for the application to move forward.

To successfully submit the Nurse 1Nys form, applicants should review their filled forms meticulously, ensure consistency in name usage across all documents, complete all sections in ink, pay attention to the detailed instruction provided, and not hesitate to ask for help if any part of the form is unclear. A careful and thorough approach when filling out the form significantly improves the likelihood of a smooth licensure process.

Documents used along the form

When applying for licensure as a nurse in New York, the Nurse Form 1 is just the starting point of gathering necessary documentation. Below are four other vital forms and documents often needed alongside the Nurse Form 1. Each plays a crucial role in ensuring that the application process runs smoothly and efficiently.

  • Form 3 - Verification of Other Professional Licensure/Certification: This form is necessary for applicants who have already been licensed or certified in a profession in any state or jurisdiction other than New York. It requires verification from the state in which the applicant is or was licensed, to confirm the status and authenticity of the previous or current license.
  • Certificate of Professional Education: This document serves as proof of the applicant's educational qualifications. It should be sent directly from the nursing school the applicant attended. For nurses educated outside the U.S., this may involve a credential evaluation report that verifies the foreign education is equivalent to a nursing program in the United States.
  • Child Abuse Identification and Reporting Coursework Certificate: New York State requires that all nurses complete training in identifying and reporting child abuse. This certificate proves that the applicant has completed the necessary training and is compliant with this requirement.
  • Infection Control Training Certificate: Similar to the child abuse identification training, this certificate confirms that the applicant has undergone mandated training on infection control practices. This training is crucial in maintaining a safe and healthy environment for patients and healthcare workers alike.

To successfully navigate the licensure process, being aware of and preparing these additional forms and documents in conjunction with the Nurse Form 1 is crucial. Each document provides essential information that supports the application, ensuring that the applicant meets all of New York State's requirements for nursing licensure.

Similar forms

The Nurse 1Nys form shares similarities with the Medical License Application form used by physicians seeking licensure to practice medicine. Both applications require detailed personal information, education history, and legal attestations regarding any previous criminal history or disciplinary action in any professional context. In addition, both forms mandate the disclosure of any pending criminal charges and require notarization to confirm the truthfulness of the provided information.

Similar to the Application for Certification in Pharmacy, the Nurse 1Nys form necessitates candidates to reveal their education background, including college and any specialized training programs. Both applications ask for a declaration of any criminal convictions and necessitate the candidate to list all states where they hold or have held a professional license, emphasizing the need for a comprehensive review of the applicant's professional conduct across different jurisdictions.

The Professional Engineering License Application parallels the Nurse 1Nys form in its requirement for applicants to detail their educational qualifications, including schools attended and degrees earned. Additionally, both forms require applicants to indicate any history of legal issues or licensure denial, revocation, or discipline in any state, alongside the provision of explanations and relevant documentation for each incident.

The Teacher Certification Application, much like the Nurse 1Nys form, insists on the applicant's full disclosure of any criminal history and contains specific sections for documenting educational coursework and qualifications. Both forms include an attestation section where the applicant must affirm the accuracy and completeness of the information provided, under the threat of potential licensure denial or legal repercussions for falsification.

Comparable to the Nurse 1Nys form, the Dental License Application form demands extensive personal identification details, including any other names used by the applicant. It similarly requires information about educational background, specific training related to dentistry, and a thorough disclosure of any criminal charges or professional disciplinary actions, ensuring the integrity and professionalism of candidates entering the field.

The Marriage and Family Therapist Licensure Application mirrors the Nurse 1Nys form in its comprehensive approach to evaluating an applicant's credentials, including educational background, practicum or internship experiences, and any other prerequisites for licensure. Each form also mandates the disclosure of personal information and any criminal or disciplinary history to evaluate the applicant's suitability for professional practice fully.

The Certified Public Accountant (CPA) License Application is akin to the Nurse 1Nys form in that it requires detailed personal information, disclosures of any criminal convictions, and a summary of educational qualifications essential for licensure. Furthermore, both applications demand information on any previous or pending disciplinary actions against the applicant in any professional context or jurisdiction, promoting transparency and accountability in the licensure process.

Dos and Don'ts

Filling out the Nurse 1NYS form is an important step toward obtaining your nursing license in New York State. Here are some dos and don'ts to help guide you through the process:

  • Do read all the instructions carefully before you start filling out the form.
  • Do ensure that the name listed on your application, photo identification, and NCLEX application match exactly to avoid delays in your testing authorization.
  • Do answer all questions in ink, using a pen or print them out from a printer, as required.
  • Do complete all parts of the application to prevent delays in its review.
  • Do sign and date the affidavit in the presence of a Notary Public as instructed on the form.
  • Don't leave the Social Security Number and Birth Date sections blank if you have a U.S. Social Security Number.
  • Don't forget to notify the Department promptly of any changes to your address or name after submitting the form.
  • Don't submit the form without checking if you are required to attach documents, such as a Certificate of Disposition for any legal issues disclosed in questions 10-14.
  • Don't overlook the fee; remember to submit the form with the appropriate fee ($143) either as a check or money order made payable to the New York State Education Department.

    • Following these guidelines will help ensure a smooth application process for your nursing licensure.

    Misconceptions

    Misunderstandings surrounding the Nurse Form 1 in New York State can lead to confusion and potential delays in the application process for licensure. Here, we clarify common misconceptions:

    • Fee Refundability: It's often assumed that if an applicant decides not to pursue licensure after submitting the Nurse Form 1 along with the fee, they are entitled to a refund. However, the application portion of the fee ($70) is non-refundable, emphasizing the importance of applicants being certain about their decision before applying.
    • Name Consistency: Some believe slight variations in the name provided across documents are permissible, but the name listed on the licensure application, photo identification, and NCLEX application must match exactly. Discrepancies, no matter how minor, can delay testing authorization and potentially incur additional fees.
    • Social Security Number Requirement: There is a misconception that a Social Security Number (SSN) is not crucial for the application. While it is mandatory for U.S. residents, applicants without an SSN should leave this part of the form blank, emphasizing the form's flexibility to accommodate diverse applicant backgrounds.
    • Public Information Disclosure: Applicants sometimes mistakenly believe they have no control over what contact information becomes public. However, the form explicitly allows applicants to designate which phone and email addresses are for business (public) or home (private) use, providing an element of privacy control.
    • Address and Name Changes: It is often overlooked that applicants are responsible for promptly notifying the Department of any name or address changes. This is crucial for maintaining accurate records and ensuring that communication regarding the licensure process is not disrupted.
    • CGFNS Records: Applicants occasionally assume that CGfNS records are irrelevant for their application. However, for those with a CGFNS record, entering the CGFNS number is essential, particularly for applicants who received their nursing education abroad.
    • Prior Licensure and Examination History: There is a misconception that past licensure and examination attempts in other states do not need to be disclosed. Complete transparency about previous applications, licenses, and exam outcomes is required, as it can impact the licensure decision.
    • Child Support Obligation Verification: Many applicants are unaware that their licensure application can be affected by their child support obligations. Those in arrears or non-compliant with child support orders may face license suspension, underscoring the significance of this section.
    • Education and Training Disclosures: Lastly, a common misunderstanding is regarding the completeness of educational and training information provided. Every detail, from elementary school through post-secondary education, must be fully documented. Incomplete information results in application delays, highlighting the need for careful attention to detail.

    Understanding these nuances ensures that applicants are better prepared for the licensure process, reducing delays and potential complications.

    Key takeaways

    Filling out the Nurse 1Nys form accurately and comprehensively is vital for aspiring nurses in New York who seek licensure in their profession. Below are key takeaways to ensure the process is smooth and successful:

    • Applicants must submit the Nurse 1Nys form along with a $143 fee, which combines both the application fee and the fee for the first registration period. It is important to note that the application portion of the fee is non-refundable.
    • Every question must be answered in ink, and all requested information provided, unless stated otherwise. Incomplete applications can lead to delays, emphasizing the importance of thoroughness.
    • The applicant's name on the licensure application, photo identification, and NCLEX application must exactly match. Discrepancies can delay testing authorization and potentially incur additional fees.
    • Applicants are required to sign and date the Affidavit section of the form in the presence of a Notary Public, underscoring the legal commitment to the truthfulness of the information provided.
    • Those with past criminal convictions or pending charges, as well as any history of professional license disciplinary actions, must provide a detailed letter and relevant court records. This documentation is crucial for a full assessment by the licensing board.
    • Educational history section must be completed in full, including all schools, colleges, or universities attended. For those educated outside the United States or in certain Canadian provinces, additional documentation, such as diplomas or transcripts, is required.
    • Applicants must also declare their child support status and citizenship or immigration status, as these areas affect eligibility for licensure.
    • Finally, additional requirements include completion of child abuse identification and reporting coursework for RN applicants. There are also specifications for infection control training, both of which may be completed within certain time frames or through approved providers.

    By closely following these guidelines and carefully filling out the Nurse 1Nys form, applicants will be better positioned to move forward in the licensing process without unnecessary hindrances. Remember, accuracy and completeness are key to a successful application.

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