Fill - Free fillable IMPORTANT PLEASE READ CAREFULLY BEFORE SUBMITTING YOUR APPLICATION (Hawaii) PDF form

IMPORTANT – PLEASE READ CAREFULLY

BEFORE SUBMITTING YOUR APPLICATION FOR

LPN, RN OR APRN LICENSE

In addition to the requirements attached to the application for a Hawaii nurse license by exam or

endorsement, the following are also required to apply for a Hawaii LPN or RN or APRN license

whether you are applying by exam, endorsement or for APRN.

Applications will not be processed or be delayed if:



An older version of the application is submitted;



Incomplete applications, not responding to all questions or failing to provide required

signed statement/explanation and court documents or Board orders for any if you

answered “yes” to the prior conviction or prior disciplinary action question or not

responding to the question truthfully;



Filing incorrect application; or



Failure to submit required documents as applicable, i.e. copy of government photo I.D.,

social security card.

Licensed Practical Nurse or Registered Nurse – Exam Applicants

•

CURRENT APPLICATION

We will only accept the most current revised applications that are posted online. No "old"

applications will be accepted. Submitting an outdated application will delay processing.

•

GOVERNMENT ISSUED IDENTIFICATION AND SOCIAL SECURITY CARD

Additional documentation required to be filed with application:



Legible copy of government issued photo ID that includes your date of birth

(same photo ID to be used for entry into the exam); and



Legible copy of your “signed” social security card.

•

CRIMINAL HISTORY RECORD CHECK

All applicants for a Hawaii nurse license are required to be fingerprinted for a criminal

history record check.

Any application received after July 1, 2017 or license issued on or after July 1, 2017 are

required to be fingerprinted.

CRIMINAL HISTORY RECORD CHECK LICENSE REQUIREMENT

REQUIREMENTS AND INSTRUCTIONS

REQUIREMENTS:

•

Any licensed issued on or after July 1, 2017 or if

you are applying for restoration or reactivating

your Hawaii nurse license (LPN, RN, APRN or

Prescriptive authority)

•

You will be required to comply with the electronic

fingerprinting requirements for the purpose of

obtaining federal (FBI national criminal history

check) and the State of Hawaii (Hawaii Criminal

Justice Data Center) criminal history record checks

in accordance with section 847-2.7.

•

ELECTRONIC FINGERPRINTING

INSTRUCTIONS:

•

Please visit Fieldprint Inc.,

at:

http://fieldprinthawaii.com to make an

appointment or to inquire about other available site

locations on the Continental United States, or call

(877) 614-4361;

•

Fieldprint code

that you must enter

FPHIBrdNursing

(not case sensitive);

•

The applicant shall bear the cost of the fingerprint

processing and all fingerprinting fees shall be paid

directly to Fieldprint; and

•

You must file your license application within thirty

(30) days of the fingerprinting to ensure that the

results can be obtained.

•

If we are unable to obtain the results, you will be

required to submit to the fingerprinting process

again.

NOTE

•

If you were previously fingerprinted by another

board of nursing or employer, you still have to

submit to the electronic fingerprinting for a Hawaii

nurse license. The Fieldprint code is specifically for

Hawaii nurse licensees and applicants.

•

If you do not use this code,

FPHIBrdNursing

(not case sensitive), we will not

be able to retrieve your report and you will have to

go back to get fingerprinted and pay another fee.

Applicants who are not in the U.S. or in a location that Fieldprint is unable

to service will have to wait until you enter the U.S. and be fingerprinted.

Please be advised that a license to practice will not be issued until the

fingerprint requirement(s) are met.

•

TRANSCRIPTS

Exam applicants and applicants for APRN license must have your transcripts requested

and sent directly from your nursing program. We will NOT accept transcripts unless they

are in a sealed envelope from your nursing program.

If you were educated outside the U.S., you must have your education reviewed by a

Board-approved credentialing organization.

Currently there are two (2) credentialing organizations approved by the Board:



CGFNS



Josef Silny & Associates, Inc., International Education Consultants

You shall make arrangements to have one of the credentialing organizations prepare a

credentials review to determine if your education is comparable to a graduate of a U.S.

accredited nursing program at the time of graduation.

The credentials evaluation must either be retrievable online directly from the

credentialing organization or directly emailed to us from the credentialing organization.

Copies will NOT be accepted.

The credentials evaluation must indicate that your education is comparable to a

graduate of a U.S. accredited nursing program without any deficiencies or your

application will be deferred.

•

AUTHORIZATION TO WORK IN THE U.S. AND SOCIAL SECURITY NUMBER/CARD

If you are not authorized to work in the U.S. and do not have a U.S. social security

number issued to you, you may still apply to sit for the NCLEX, however, upon passing,

you may be issued a conditional approval.

This conditional approval is NOT a license to practice nursing. Once you enter the U.S.,

you will be required to complete your fingerprinting and once you can provide proof of

your authorization to work in the U.S. and a signed social security card, a nurse license

may be issued.

When submitting your application, should you answer “No” to the question “Are you a

U.S. citizen, a U.S. national, or an alien authorized to work in the United States?, you

may submit a signed statement clarifying that you currently reside outside the U.S. and

is currently not authorized to work in the U.S. nor do you have a U.S. social security

card/number and understand that upon approval and passing the exam you may be

issued a conditional approval until you provide official documentation that you are

authorized to work in the U.S. and your social security card. This statement will assist in

processing your application more efficiently as we will not assume that you responded to

this question in error.

•

FAILING THE NCLEX

If you have failed the NCLEX PN or NCLEX RN three (3) times, regardless of which

state or jurisdiction you were made eligible (

If you were previously approved to sit for the

NCLEX in another state and failed the exam, those failed attempts will count towards the

3 times.

), you will be required to complete a board approved remedial course before

being approved to sit for the NCLEX pursuant to the following administrative rules:

§16-89-9 Examination policies.

(a) The passing standards for the NCLEX-RN

and NCLEX-PN examinations accurately reflect the amount of nursing ability currently

required to practice competently at the entry level. The passing standards for the

NCLEX-RN and the NCLEX-PN shall be established by the National Council of State

Boards of Nursing unless otherwise determined by the board.

(b) Candidates may take the examination, provided candidates register for

each examination. Any candidate who fails the license examination three times,

regardless of when or where the examination was taken, and regardless of which state

or jurisdiction the candidate was made eligible, shall be required to complete a board-

approved remedial course and submit proof of passing the course before the candidate

may be approved for reexamination. The candidate shall apply for reexamination within

six months after completion of the remedial course. After taking the remedial course, the

candidate may be approved to retake the examination up to three additional times before

the candidate is required to take remediation again.

"Remedial course" means a course that is approved by the board and meets the

requirements of subchapter 8 and shall include a minimum of sixty hours of didactic

instruction and sixty hours of clinical instruction.

Licensed Practical Nurse or Registered Nurse – Endorsement Applicants

•

CURRENT APPLICATIONS

We will only accept the most current revised applications that are posted online. No "old"

applications will be accepted. Submitting an outdated application will delay processing.

•

CRIMINAL HISTORY RECORD CHECK

All applicants for a Hawaii nurse license are required to be fingerprinted for a criminal

history record check.

Any application received after July 1, 2017 or license issued on or after July 1, 2017 are

required to be fingerprinted.

CRIMINAL HISTORY RECORD CHECK LICENSE REQUIREMENT

REQUIREMENTS AND INSTRUCTIONS

REQUIREMENTS:

•

Any licensed issued on or after July 1, 2017 or if

you are applying for restoration or reactivating

your Hawaii nurse license (LPN, RN, APRN or

Prescriptive authority)

•

You will be required to comply with the electronic

fingerprinting requirements for the purpose of

obtaining federal (FBI national criminal history

check) and the State of Hawaii (Hawaii Criminal

Justice Data Center) criminal history record checks

in accordance with section 847-2.7.

•

ELECTRONIC FINGERPRINTING

INSTRUCTIONS:

•

Please visit Fieldprint Inc.,

at:

http://fieldprinthawaii.com to make an

appointment or to inquire about other available site

locations on the Continental United States, or call

(877) 614-4361;

•

Fieldprint code

that you must enter

FPHIBrdNursing

(not case sensitive);

•

The applicant shall bear the cost of the fingerprint

processing and all fingerprinting fees shall be paid

directly to Fieldprint; and

•

You must file your license application within thirty

(30) days of the fingerprinting to ensure that the

results can be obtained.

•

If we are unable to obtain the results, you will be

required to submit to the fingerprinting process

again.

NOTE

•

If you were previously fingerprinted by another

board of nursing or employer, you still have to

submit to the electronic fingerprinting for a Hawaii

nurse license. The Fieldprint code is specifically for

Hawaii nurse licensees and applicants.

•

If you do not use this code,

FPHIBrdNursing

(not case sensitive), we will not

be able to retrieve your report and you will have to

go back to get fingerprinted and pay another fee.

Applicants who are not in the U.S. or in a location that Fieldprint is unable

to service will have to wait until you enter the U.S. and be fingerprinted.

Please be advised that a license to practice will not be issued until the

fingerprint requirement(s) are met.

•

NATIONAL PRACTITIONERS DATA BANK SELF-QUERY REPORT

If you are applying for a Hawaii LPN or RN license and are licensed as an LPN or RN

under the laws of another state, territory, or foreign country, you will be required to

submit a self-query report from the National Practitioner Data Bank ("NPDB").

To obtain the report, go to the NPDB website at: www.npdb.hrsa.gov and click on

Perform a Self-Query. If you are unable to go on-line, call NPDB at 1-800-767-6732 for

assistance. After you receive this report, send the PDF original report to the Board of

Nursing.

The NPDB self-query report is available for download. The Board of Nursing will accept

either the ORIGINAL hard copy that is mailed to you from the NPDB or the ORIGINAL

PDF emailed report. You will need to attach the PDF file in the email. Please forward the

PDF report to nursing@dcca.hawaii.gov. Copies or “pictures” of the NPDB self-query

report is not acceptable and we do not open secured files or links.

Advanced Practice Registered Nurse (“APRN”) Applicants

•

CURRENT APPLICATIONS

We will only accept the most current revised applications that are posted online. No "old"

applications will be accepted. Submitting an outdated application will delay processing.

•

CURRENT HAWAII RN LICENSE

In order to obtain or maintain a Hawaii APRN license, you must have a current and valid

Hawaii RN license.

If you are applying for both the Hawaii RN and APRN license, you may submit your

applications at the same time and need not wait until a Hawaii RN license is issued to

you.

•

CRIMINAL HISTORY RECORD CHECK

All applicants for a Hawaii nurse license are required to be fingerprinted for a criminal

history record check.

Any application received after July 1, 2017 or license issued on or after July 1, 2017 are

required to be fingerprinted.

CRIMINAL HISTORY RECORD CHECK LICENSE REQUIREMENT

REQUIREMENTS AND INSTRUCTIONS

REQUIREMENTS:

•

Any licensed issued on or after July 1, 2017 or if

you are applying for restoration or reactivating

your Hawaii nurse license (LPN, RN, APRN or

Prescriptive authority)

•

You will be required to comply with the electronic

fingerprinting requirements for the purpose of

obtaining federal (FBI national criminal history

check) and the State of Hawaii (Hawaii Criminal

Justice Data Center) criminal history record checks

in accordance with section 847-2.7.

•

ELECTRONIC FINGERPRINTING

INSTRUCTIONS:

•

Please visit Fieldprint Inc.,

at:

http://fieldprinthawaii.com to make an

appointment or to inquire about other available site

locations on the Continental United States, or call

(877) 614-4361;

•

Fieldprint code

that you must enter

FPHIBrdNursing

(not case sensitive);

•

The applicant shall bear the cost of the fingerprint

processing and all fingerprinting fees shall be paid

directly to Fieldprint; and

•

You must file your license application within thirty

(30) days of the fingerprinting to ensure that the

results can be obtained.

•

If we are unable to obtain the results, you will be

required to submit to the fingerprinting process

again.

NOTE

•

If you were previously fingerprinted by another

board of nursing or employer, you still have to

submit to the electronic fingerprinting for a Hawaii

nurse license. The Fieldprint code is specifically for

Hawaii nurse licensees and applicants.

•

If you do not use this code,

FPHIBrdNursing

(not case sensitive), we will not

be able to retrieve your report and you will have to

go back to get fingerprinted and pay another fee.

Applicants who are not in the U.S. or in a location that Fieldprint is unable

to service will have to wait until you enter the U.S. and be fingerprinted.

Please be advised that a license to practice will not be issued until the

fingerprint requirement(s) are met.

If you were previously fingerprinted in order to receive a Hawaii RN or LPN license after July 1,

2017, you need not be fingerprinted again when applying for the APRN license.

•

NATIONAL PRACTITIONERS DATA BANK SELF-QUERY REPORT

If you are applying for a Hawaii LPN, RN license or APRN and are currently licensed or

was licensed as an LPN, RN or APRN under the laws of another state, territory, or

foreign country, you will be required to submit a self-query report from the National

Practitioner Data Bank ("NPDB").

To obtain the report, go to the NPDB website at: www.npdb.hrsa.gov and click on

Perform a Self-Query. If you are unable to go on-line, call NPDB at 1-800-767-6732 for

assistance. After you receive this report, send the PDF original report to the Board of

Nursing.

The NPDB self-query report is available for download. The Board of Nursing will accept

either the ORIGINAL hard copy that is mailed to you from the NPDB or the ORIGINAL

PDF emailed report. You will need to attach the PDF file in the email. Please forward the

downloaded PDF report to nursing@dcca.hawaii.gov. Copies or “pictures” of the NPDB

self-query report is not acceptable and we do not open secured files or links.

Prescriptive Authority for Advanced Practice Registered Nurse (“APRN”) Licensees

If you are currently licensed as a Hawaii APRN and wish to apply for prescriptive authority as a

“privilege” under your APRN license, you must complete the application for “Advanced Practice

Registered Nurse Prescriptive Authority”.

If you are applying for initial license as a Hawaii APRN with prescriptive authority, you may use

the APRN license application and you do not need to complete this application. This is

application is only for currently licensed Hawaii APRNs.

•

CURRENT APPLICATIONS

We will only accept the most current revised applications that are posted online. No "old"

applications will be accepted. Submitting an outdated application will delay processing.

There are no fees for this application.

•

CURRENT HAWAII RN AND APRN LICENSE

In order to apply for prescriptive authority, you must have a current and valid Hawaii RN

and APRN license.

•

CRIMINAL HISTORY RECORD CHECK

All applicants for a Hawaii nurse license and for prescriptive authority are required to be

fingerprinted for a criminal history record check.

Any application received after July 1, 2017 or license issued on or after July 1, 2017 are

required to be fingerprinted.

CRIMINAL HISTORY RECORD CHECK LICENSE REQUIREMENT

REQUIREMENTS AND INSTRUCTIONS

REQUIREMENTS:

•

Any licensed issued on or after July 1, 2017 or if

you are applying for restoration or reactivating

your Hawaii nurse license (LPN, RN, APRN or

Prescriptive authority)

•

You will be required to comply with the electronic

fingerprinting requirements for the purpose of

obtaining federal (FBI national criminal history

check) and the State of Hawaii (Hawaii Criminal

Justice Data Center) criminal history record checks

in accordance with section 847-2.7.

•

ELECTRONIC FINGERPRINTING

INSTRUCTIONS:

•

Please visit Fieldprint Inc.,

at:

http://fieldprinthawaii.com to make an

appointment or to inquire about other available site

locations on the Continental United States, or call

(877) 614-4361;

•

Fieldprint code

that you must enter

FPHIBrdNursing

(not case sensitive);

•

The applicant shall bear the cost of the fingerprint

processing and all fingerprinting fees shall be paid

directly to Fieldprint; and

•

You must file your license application within thirty

(30) days of the fingerprinting to ensure that the

results can be obtained.

•

If we are unable to obtain the results, you will be

required to submit to the fingerprinting process

again.

NOTE

•

If you were previously fingerprinted by another

board of nursing or employer, you still have to

submit to the electronic fingerprinting for a Hawaii

nurse license. The Fieldprint code is specifically for

Hawaii nurse licensees and applicants.

•

If you do not use this code,

FPHIBrdNursing

(not case sensitive), we will not

be able to retrieve your report and you will have to

go back to get fingerprinted and pay another fee.

Applicants who are not in the U.S. or in a location that Fieldprint is unable

to service will have to wait until you enter the U.S. and be fingerprinted.

Please be advised that a license to practice will not be issued until the

fingerprint requirement(s) are met.

If you were previously fingerprinted in order to receive a Hawaii LPN, RN or APRN license after

July 1, 2017, you need not be fingerprinted again when applying for the APRN license.

•

RENEWAL REQUIREMENTS FOR PRESCRIPTIVE AUTHORITY

Please be advised that the prescriptive authority you are applying for is a

“privilege” attached to your APRN license and must be renewed.

At the time of renewal, you will be asked if you wish to “renew” your prescriptive

authority. If you answer “yes”, your prescriptive authority will be renewed along

with your APRN license. If you fail to indicate “yes” or leave blank, your

prescriptive authority will NOT be renewed.

You will have until December 31 of the odd-numbered year to restore your

prescriptive authority. If you do not restore your prescriptive authority by the end

of December of the odd-numbered year, you will have to reapply as a new

applicant for prescriptive authority and meet all current requirements.

Any APRN who fails to renew his or her prescriptive authority and continues to

practice as an APRN with prescriptive authority shall be considered an illegal

practitioner and shall be subject to penalties provided for by law.

REQUIREMENTS FOR LICENSE - NURSE (ENDORSEMENT OR WITHOUT EXAM)

Access this form via website at: cca.hawaii.gov/pvl/boards/nursing

The Board's mailing address is: The Board's street address is:

Board of Nursing

P.O. Box 3469

Honolulu, HI 96801

Phone: (808) 586-3000

Board of Nursing

335 Merchant Street, Room 301

Honolulu, HI 96813

PLEASE READ ALL INSTRUCTIONS BEFORE COMPLETING THE APPLICATION

Licensing Requirements:

This application is for individuals who meet the following requirements (If you are applying to take the NCLEX exam, DO

NOT COMPLETE THIS APPLICATION. Please see application for Nurse License by Exam):

•

License - Verification of license completed by the originating state board verifying:

i. Nurse license number, effective and expiration dates;

ii. Completion of a U.S. accredited nursing program or nursing program approved by the state board as being equivalent

to a U.S. accredited nursing education program (See education requirements listed below);

iii. Exam score and exam series (See exam requirements below);

iv.

Whether or not the nurse license has ever been disciplined and if there are any encumbrances on the license; and

Verification of nurse license held in any other state or U.S. jurisdiction, whether the license is current or expired.

Exam - Successfully passed one of the following examinations:

i. The NCLEX (National Council Licensure Examination) in another state or U.S. jurisdiction;

ii. The SBTPE (State Board Test Pool Exam) in another state or Canadian province (prior to 1970); or

iii. A state board constructed exam prior to the inception of the SBTPE in that jurisdiction.

Education - Successfully completed one of the following:

ii.

U.S. Nursing Programs - Graduate of a state-approved or nationally accredited baccalaureate, the pre-licensure portion

of a graduate entry program in nursing, an associate degree or diploma nursing program in the United States or United

States jurisdiction; or

Foreign Nursing Programs - If your nursing program is not U.S. accredited or approved by another state board, you

must have your credentials evaluated by a professional education credentials evaluator recognized by the Board that

indicates successful completion of a nursing program that is comparable to an accredited nursing program in the United

States.

NSG-07 1220R

(CONTINUED ON PAGE 2)

Criminal History Record Check Federal Bureau Of Investigation ("FBI") Report -

All applicants are required to submit to a FBI fingerprint check through the Hawaii Criminal Justice Data Center (HCJDC). To

obtain a FBI national Criminal History Record check and the State of Hawaii Criminal History Record check, applicants shall be

fingerprinted electronically at Fieldprint Inc. locations nationwide or any other fingerprinting agency approved to send

electronic fingerprints to the Hawaii Criminal Justice Data Center ("HCJDC").

Please visit Fieldprint Inc. at: http://fieldprinthawaii.com to make an appointment, inquire about other available site

locations on the Continental United States, or call (877) 614-4361.

Fees for the FBI and the State of Hawaii Criminal History Record checks shall be paid directly to Fieldprint and will be

electronically sent to the HCJDC.

NOTE: A license application must be filed within 30 days of the fingerprinting to ensure that the results are obtainable from

the HCJDC. If the results are not obtainable, you will be required to obtain new fingerprints.

•

Your Social Security Number is used to verify your identity for licensing purposes and for compliance with the below laws.

For a license to be issued you must provide your Social Security Number or your application will be deemed deficient

and will not be processed further.

The following laws require that you furnish your Social Security Number to our agency:

FEDERAL LAWS:

42 U.S.C.A. §666(a)(13) requires that Social Security Number of any applicant for a professional license or occupational

license be recorded on the application for license; and

If you are a licensed health care practitioner, 45 C.F.R., Part 61, Subpart B, §61.7 requires the Social Security Number as part

of the mandatory reporting we must do to the Healthcare Integrity and Protection Data Bank (HIPDB), of any final adverse

licensing action against a licensed health care practitioner.

HAWAII REVISED STATUTES ("HRS"):

§576D-13(j), HRS requires the Social Security Number of any applicant for a professional license or occupational license be

recorded on the application for license; and

§436B-10(4), HRS which states that an applicant for license shall provide the applicant's Social Security Number if the

licensing authority is authorized by federal law to require the disclosure (and by the federal cites shown above, we are

authorized to require the Social Security Number).

(CONTINUED ON PAGE 3)

-2-

Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the

FBI. Your fingerprints will also be retained by the HCJDC and the FBI for all purposes and uses authorized for fingerprint

submissions, which may include participation in the state and national rap back programs. You have the opportunity to

complete or challenge the accuracy of the information contained in the FBI identification record. The procedure for

obtaining a change, correction, or updating an FBI identification record are set forth in Title 28, CFR, 16.34.

Filing Instructions:

Please read the requirements and instructions before completing the application. Incomplete applications will delay

processing time which is normally 15-20 working days.

•

Complete on-line fillable form or print legibly in black ink.

Answer all questions. If not applicable, indicate "N/A".

Sign and date application.

Social Security Number - Please indicate your Social Security Number

Criminal History Record Check Federal Bureau Of Investigation ("FBI") Report (cont'd) -

•

Documentation Requirements for "YES" Answers to Questions (3), (4) OR (5) -

•

The following documentation/materials must be submitted with the license application or submitted directly from the

official source. Applications will not be processed without this documentation/materials.

If you answered "YES" to question #3, "Have you ever been convicted of a crime in any jurisdiction that has not been

annulled or expunged?", you must submit the following:

A detailed statement signed by you explaining the underlying circumstances that led to the conviction(s);a)

Certified copies of court documents related to the conviction that include but is not limited to the indictment(s),

judgments, disposition of the court, terms of sentence and sanctions. Also, if applicable, proof of compliance with

any sanctions imposed by the court(s) i.e. proof of payment of fines, completion of course, etc; and

If you are currently on parole or probation, a certified copy of the terms of the parole or probation and a statement

from your parole or probation officer as to your compliance with the court orders.

(CONTINUED ON PAGE 4)

-3-

A detailed statement signed by you explaining the underlying circumstances that led to the disciplinary action(s);

and

Certified copies of any documents from the agency (other Board of Nursing) including final orders, petitions,

complaints, findings of fact and conclusions of law, consent orders, and any other relevant documents.

A detailed statement signed by you explaining the underlying circumstances that led to the disciplinary action(s);

and

3. If you answered "YES" to question #5, "Are you presently being investigated or is any disciplinary action pending against

you?", you must submit the following:

b) Certified copies of any documents from the agency (other Board of Nursing) including petitions, complaints,

findings of fact and conclusions of law, consent orders, and any other relevant documents.

If you previously filed an application for nurse license and provided the previous information and was approved by the Board

and have not had any subsequent convictions, disciplinary actions or are currently being investigated, then you may submit

a signed statement indicating that the information was previously disclosed and documents submitted and that there has

not been any subsequent convictions, disciplinary actions or pending investigations.

Also, for any pending disciplinary actions or investigations, you are required to report the outcome with documentation of

the investigation within thirty (30) days of the disposition.

Fees -

ATTACH a personal check, money order, or cashier's check for the appropriate amount made payable to: COMMERCE &

CONSUMER AFFAIRS. (check must be in U.S. dollars and be from a U.S. financial institution.)

If license will be issued between JULY 1, ODD-NUMBERED years (2015, 2017, 2019) and

JUNE 30, EVEN-NUMBERED years (2016, 2018, 2020), pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $234.00

(Application** - $40, License - $36, Compliance Resolution Fund*** - $100,

1/2 Renewal - $18, Center for Nurse Fee**** - $40)

*If license will be issued between JULY 1, EVEN-NUMBERED years (2016, 2018, 2020) and

JUNE 30, ODD-NUMBERED years (2017, 2019, 2021), pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $166.00

(Application** - $40, License - $36, Compliance Resolution Fund*** - $50,

Center for Nurse Fee**** - $40)

If you answered "YES" to question #4, "Has any license ever been revoked, suspended, or otherwise subject to

disciplinary action by the Hawaii State Board or another state board?", you must submit the following:

•

* SUBJECT TO RENEWAL BY JUNE 30, ODD-NUMBERED YEARS (2015, 2017, 2019), REGARDLESS OF ISSUE DATE.

PLEASE READ DETAILED INFORMATION UNDER LICENSE RENEWALS.

** Application fee is not refundable.

*** The Compliance Resolution Fund (CRF) was established by the 1982 Legislature (§26-9(m), Hawaii Revised Statutes)

to expedite resolution of consumer complaints filed with the Department of Commerce and Consumer Affairs.

Assessment amounts are based on the services rendered in resolving complaints. Assessment is due for the

issuance of a new license as well as for the renewal of a license.

**** Act 198 (effective July 1, 2003) establishes a Center for Nursing (Center) at the University of Hawaii School of Nursing

and Dental Hygiene. The Center will help to ensure that better data about nurses is available, which will improve

health care in Hawaii, as well as working conditions for nurses. The Center will collect and analyze data and prepare

and disseminate written reports and recommendations regarding the current and future status and trends of the

nursing workforce. The Center will conduct research on best practices and quality outcomes, as well as, develop a

plan for implementing strategies to recruit and retain nurses. Act 198 establishes a special fund to support the

Center's activities and requires the assessment of a $40 fee upon the issuance of a new nurse license and at each

license renewal. Beginning on July 1, 2003, each new license will be assessed the $40 fee to support the Center, and

beginning with the 2005 renewal, the fee will be assessed for each license renewal.

•

Documentation Requirements for "YES" Answers to Questions (3), (4) OR (5) (cont'd) -

NOTE: One of the numerous legal requirements that you must meet in order for your new license to be issued is the

payment of fees as set forth in this application. you may be sent a license certificate before the payment you sent us for your

required fees is honored by your bank. If your payment is dishonored, you will have failed to pay the required licensing fee

and your license will not be valid, and you may not do business under that license. Also, a $25.00 service charge shall be

assessed for payments that are dishonored for any reason.

If for any reason you are denied the license you are applying for, you may be entitled to a hearing as provided by Title 16, Chapter

201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes. Your written request for a hearing must be directed

to the agency that denied your application, and must be made within 60 days of notification that your application for license has

been denied.

•

Verification of your exam scores, educational credentials and out-of-state licensure must be completed. Send your request

to the state/territory board of nursing of ORIGINAL LICENSURE BY EXAMINATION with the appropriate service fee that the

originating board requires. Please verify with the respective state board for fee information.

•

PROVIDE DATE YOU REQUESTED A LICENSE VERIFICATION FROM YOUR ORIGINAL STATE (See application).

If your state uses NURSYS to verify their licenses, you must contact the National Council via their website at:

www.nursys.com, and request a verification of your license.

License verifications are valid for one year only. If no Hawaii nurse application is received within that 1 year, a new

verification of license will be required.

•

All applicants/licensees are responsible for reading, being knowledgeable and maintaining current knowledge of the Hawaii

Revised Statutes (laws) Chapter 457 and Administrative Rules Title 16, Chapter 89 relating to nursing and any amendments

adopted throughout the years. In addition, applicants/licensees shall be responsible for reading, being knowledgeable and

maintaining current knowledge of Chapter 436B, Hawaii Revised Statutes, the Professional and Vocational Licensing Act.

These laws and rules are posted on the Board's website at: cca.hawaii.gov/pvl/boards/nursing. Under "Nursing

Spotlight", click on "Statute/Rule Chapter".

-4-

(CONTINUED ON PAGE 5)

•

If an agency or individual is assisting you with the licensure process, you must complete the authorization portion "Release

of Information to Third Party", sign and date it. If you do not complete this portion, we will not be able to release or discuss

any information pertaining to your pending application.

Fees (cont'd) -

•

Verification(s) of license from other states or jurisdictions -

State Nursing Laws and Rules -

Release of information to third party -

Pursuant to HRS §436B-9 your application shall be considered abandoned and shall be destroyed if you fail to provide

evidence of continued efforts to complete the licensing process for two consecutive years. The failure to provide evidence of

continued efforts includes but is not limited to: (1) failure to submit any required information and documents requested by

the licensing authority within two consecutive years from the last date the documents and other information were

requested, or (2) failure to complete any additional requirements for licensure that remains after approval of your

application, such as attempting to complete an exam requirement, within two consecutive years from the date your

application was approved, or (3) failure to provide the licensing authority with any written communication during two

consecutive years indicating that you are attempting to complete the licensing process. If an application is deemed

abandoned the applicant shall be required to reapply for licensure and comply with the licensing requirements in effect at

the time of the reapplication.

•

Abandonment of application -

It is the responsibility of the applicant/licensee to notify this office of any changes in writing. If you have a name change

after your application was originally filed, you must provide a photocopy of the name change document, i.e. marriage

license, along with a letter requesting the change. If you have a name change after you are licensed, you may also submit

$10 with the name change document and request, for a duplicate pocket card to be issued under your new name. Address

changes must also be submitted in writing. No changes will be taken over the phone. Notification by email is acceptable

provided the appropriate documents are included.

•

Address and Name changes -

To obtain a temporary permit, you must complete the application and submit the following in order for us to process your

temporary permit in a timely manner:

•

ii.

Pay the separate fee of $50 for the temporary permit.

The attached application for license (without exam)

A verification of a current U.S. nursing license indicating the expiration date of license.

A completed original "Verification of Employment" form (NSG-05) which must first be signed by your employer in

Hawaii. Letters of hire will not be accepted.

Proof of mailing the "Verification of License" form (NSG-03) OR NURSYS verification (receipt of certified mail, copy of the

cancelled check for the verification fee).

iii.

iv.

Only ONE temporary permit is allowed. Permittee is allowed to practice nursing only if employed by employer

indicated on the "Verification of Employment" form (NSG-04). Once permit is issued, no other will be reissued in care

of another employer. PRIOR DISCIPLINARY ACTION OR CONVICTION, WHICH HAS NOT BEEN EXPUNGED, MUST BE

REVIEWED BY THE BOARD.

•

All licenses, regardless of issuance date, expire on June 30 of each odd-numbered year and are subject to renewal.

Renewal applications are made available about 60 days prior to the license expiration date. Effort will be made to mail

notification to licensees upon request only or pick one up at: 335 Merchant Street, Room 301, in Honolulu, Hawaii. EACH

LICENSEE IS ULTIMATELY RESPONSIBLE FOR THE RENEWAL OF HIS HER NURSING LICENSE. However, the Board must be

informed in a timely manner of any address changes in writing. The Board will not negotiate this matter with the employers

for a licensee who has not timely renewed a nursing license. AT NO TIME MAY A NURSE, WHOSE LICENSE HAS LAPSED,

CONTINUE TO PRACTICE AS A NURSE. IT IS THE NURSE'S DUTY TO INFORM EACH EMPLOYER WHO IS IMPACTED, OF THE

NURSE'S FAILURE TO RENEW A NURSING LICENSE ON TIME. Online renewal of a nurse license is available to licensees who

have not had any disciplinary action pending or taken or have not had a conviction during the two years prior to the renewal

date.

-5-

Temporary permit -

Renewal requirements -

•

If you are eligible for a license near the end of the second year of a two-year license period (within 3 months), you may

elect to delay the issuance of your license until July 1, odd-numbered year, provided you do not intend to start

practicing nursing until the next license period.

For more information on initial and renewal license requirements, inactive/reactivation requirements, etc., go the the

Board of Nursing's web page at: cca.hawaii.gov/pvl/boards/nursing. Look under "Nursing Spotlight" and click on

"FAQ's".

Continuing Competency:

Beginning on July 1, 2017, all Hawaii nurse licensees who do not meet one of the exemptions will be required to complete one of

the learning activity options for continuing competency prior to the renewal of his/her Hawaii nurse license in 2019. Please

review the Continuing Competency Booklet located on the Board's web page at: cca.hawaii.gov/pvl/boards/nursing.

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit

your request.

Print Form

APPLICATION FOR LICENSE (ENDORSEMENT OR

WITHOUT EXAM) - NURSE

BOARD USE ONLY

Read the Instructions before completing this form.

Access this form via our website at: cca.hawaii.gov/pvl/boards/nursing

Check type of LICENSE applying for: REGISTERED NURSE PRACTICAL NURSE

Approved:

Initials/Date:

Lic. No. Effective Date:

Temp. No. Effective Date:

Legal Name (First, Middle): (Last):

Residence Address (Include Apt. No., City, State and Zip Code):

Mailing Address (ONLY if different from above):

Other Names Used (Include maiden name):

U.S. Social Security No.:

Phone No. (Daytime):

OTHER STATE LICENSES

Name of State Type of License Method of LicensureLicense No.

Provide date

"Verification of

License" was

requested

ORIGINAL U.S. State

Other State

RN LPN

LPN

SBTPENCLEX

State

Exam

Waiver of

Exam

Check answers. If response is "YES" to questions 3 to 5, provide a signed written statement explaining the circumstances and give

details when required in addition to the documents requested below.

NCLEX SBTPE

State

Exam

Waiver of

Exam

NCLEX SBTPE

State

Exam

Waiver of

Exam

1. Are you at least 18 years of age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

2. Are you a U.S. citizen, a U.S. national, or an alien authorized to work in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

3. Have you ever been convicted of a crime in any jurisdiction that has not been annulled or expunged? . . . . . . . . . . . . . . . . .

Yes No

If "YES", you are required by law to arrange to have certified court documentation on the date, place,

violation for each conviction and fulfillment of conditions of each sentence sent directly to the Board.

4. Has any license ever been revoked, suspended, or otherwise subject to disciplinary action by the Hawaii

State Board or another state board? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

If "YES", you are required by law to arrange to have certified documents from each state in which disciplinary

action was taken sent directly to the Board. (Include Findings of Fact, Conclusion of Law, Recommended Order,

Final Order, and whether you have been re-instated. If re-instated, date and conditions of license.)

NSG-02 1220R

App . . . . . . . . . . . . . . . . 433 . . . . . . . . . . . . . . . . . $40

Lic. . . . . . . . . . . . . . . . . . 436 . . . . . . . . . . . . . . . . . $36

Center for Nurse. . . . CFN . . . . . . . . . . . . . . . . $40

CRF. . . . . . . . . . . . . . . . . 439 . . . . . . . . . . . . . . . . . $50/$100

1/2 Ren. . . . . . . . . . . . . 430 . . . . . . . . . . . . . . . . . $18

Service Charge. . . . . . BCF . . . . . . . . . . . . . . . . . $25

(CONTINUED ON PAGE 2)

Date of Birth: Personal Email Address:

You may attach additional sheet as needed.

• Provide date you were fingerprinted to obtain the national (FBI) and State

Criminal History Record Check.

Date:

CBC: EO:

Print Name of Nurse:

6. Have you ever held this type of nursing license in Hawaii? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

a) If "YES", are you re-applying for a license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

Provide your license number: and date license was issued:

b) Have you actively practiced nursing in Hawaii or any other State in the U.S. or U.S. territory within the

past 5 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

If "YES", provide a copy of license. If "NO", you may be required to submit proof of continued competency

by retaking and passing the NCLEX or complete continuing education recognized by the Board.

EDUCATION

Name and Location (city/state) Degree Earned

Dates (mo/yr)

From To

Nursing School

Advanced Training

AFFIDAVIT OF APPLICANT:

I hereby certify that the statements, answers, and representations made in this application and in the documents attached are true

and correct. I understand that any misrepresentation is grounds for refusal to grant or subsequent revocation of license and is a misdemeanor

(Section 710-1017, Sections 436B-19, and 457-12, Hawaii Revised Statutes.)

I further certify that I have read and will abide by the provisions of Hawaii Revised Statutes, Chapter 457 and 436B and Hawaii

Administrative Rules, Chapter 89.

I hereby certify that I will authorize the Board of Nursing to provide my email to the Hawaii State Center for Nursing (HSCN) to collect

and analyze workforce data. The HSCN will handle my information in a secure and confidential manner and my email will not be shared

without my authorization.

Signature of Applicant

Date

-2-

Date:

NOTE: PRIOR DISCIPLINARY ACTION OR CONVICTION, WHICH HAS NOT BEEN ANNULLED OR EXPUNGED, MUST BE REVIEWED BY THE

BOARD. Failure to provide the requested information above will delay the processing of your application.

If "YES", specify all states where action was or may be imposed. You are required to arrange to have certified

documents from each state in which disciplinary action or investigation occurred or is pending against you sent

directly to the Board.

5. Are you presently being investigated or is any disciplinary action pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

(CONTINUED ON PAGE 3)

Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. Your

fingerprints will also be retained by the HCJDC and the FBI for all purposes and uses authorized for fingerprint submissions, which may include

participation in the state and national rap back programs. You have the opportunity to complete or challenge the accuracy of the information

contained in the FBI identification record. The procedure for obtaining a change, correction, or updating an FBI identification record are set

forth in Title 28, CFR, 16.34.

Print Name of Nurse: Date:

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

-3-

Release of Information to Third Party:

To assist me in the licensing process, I authorize the BON and staff to release any and all information regarding my application (including but

not limited to, application status) to the following:

Name of Individual who is assisting you:

Name of Organization:

Address of Organization:

Signature of Applicant

Date

Print Form

VERIFICATION OF LICENSE - NURSE

APPLICANT: Complete Applicant section and mail to all state boards of nursing where you hold or ever held a license (including where

you took the licensing examination). CONTACT THAT BOARD OF NURSING FOR THEIR PROCEDURES AND FEES. If the state is a member of

the NURSYS System, you will need to contact them toll free at (866) 819-1700 to request a license verification form or you may download the

form from their website at: www.nursys.com

APPLICANT

Legal Name (First, Middle) (Last) Other Names Used (Include maiden name)

Address (Include Apt. No., City, State and Zip Code) Social Security No.

Phone No.

LICENSE NUMBER DATE ISSUED:

Type of Registration:

REGISTERED NURSE PRACTICAL NURSE

I hereby authorize the nursing licensing agency in the State of to furnish to the Department of

Commerce & Consumer Affairs, State of Hawaii, the information below.

SIGN HERE: Date:

LICENSING AGENCY ONLY

This is to certify that the above-named individual was issued license number:

Social Security Number:

Date of Issuance:

to practice:

Registered Nursing

Practical Nursing

licensed by:

Examination

Endorsement

Waiver

Current license status:

Active

Inactive

Lapsed

Date license expires:

Has this license ever been encumbered in any way (revoked,

suspended, surrendered, limited, placed on probation)? . . . . . . . .

Yes No

If "YES", please send a copy of your board's:

1) Administrative Action

2) Final Order

EXAMINATION

INFORMATION

REGISTERED

NURSE

(NCLEX)

REGISTERED NURSE (S.B.T.P.E.)

PRACTICAL

NURSE

(NCLEX or SBTPE)

Medical

Nursing

Psychiatric

Nursing

Obstetric

Nursing

Surgical

Nursing

Nursing of

Children

Standard Scores

Series/Form No.

Number of times applicant wrote the examination?

Name of U.S. Accredited Nursing Education Program Completed (or non-U.S. Accredited Nursing Education Program approved/recognized

by this State Board as equivalent to U.S. Accredited Nursing Education Program.)

Location (City and State) Year of Graduation:

Signature:

Title:

State: Date:

SEAL

NSG-03 1220R

TO THE BOARD: Return this form directly to: Hawaii Board of Nursing

P.O. Box 3469

Honolulu, HI 96801

This material can be made available for

individuals with special needs. Please call

(808) 586-3000 to submit your request.

Date of Birth

Personal Email Address

Print Form

Pursuant to §436B-9, Hawaii Revised Statutes, your application shall be considered abandoned and shall be destroyed if you fail to

provide evidence of continued efforts to complete the licensing process for two consecutive years. The failure to provide evidence

of continued efforts includes, but is not limited to:

(1) failure to submit any required information and documents requested by the licensing authority within two consecutive

years from the last date the documents and information were requested, or

(2) failure to complete any additional requirements for licensure that remain after approval of your application, such as

attempting to complete an examination requirement, within two consecutive years from the date your application was approved,

(3) failure to provide the licensing authority with any written communication during two consecutive years indicating that

you are attempting to complete the licensing process.

If an application is deemed abandoned, the applicant shall be required to reapply for licensure and comply with the licensing

requirements in effect at the time of the reapplication.

Frequently Asked Questions regarding Abandoned Applications

1) Q: If after receiving my application the board or program requests additional information, how much time do I

have to provide them with the requested information before my application is deemed abandoned?

A: You have two years from the date the information is requested.

2) Q: If I am an applicant who is required to take a licensing examination in order to complete the licensing process

and my application to take the licensing examination is approved, how much time do I have to complete the

examination requirement before my application is abandoned?

A: You must make an attempt to take the examination within two years from the date your application is

approved.

3) Q: What is meant by "attempt to take the examination?"

A: You must register and take the examination.

4) Q: If the statutes or rules of the boards or programs do not set time limits on taking and passing the examination,

and the only requirement left for me to become licensed is to pass the examination, and within the two year

period I should fail the examination, re-register for the examination, but fail again, will my application be

abandoned because I could not pass the examination within two years?

A: Your application will not be abandoned because you would have demonstrated your efforts to take the

examination by registering for and taking the examination.

(NOTE: Our office will only be notified of your efforts if you take the examination as a Hawaii candidate.

Examination results will not automatically be provided to our office if you sit for the examination via another

state board. Therefore, if you are in this situation, please arrange for the test results to be sent to us).

5) Q: What does it mean if my application is abandoned?

A: It means that your application is no longer valid, will be destroyed, and you shall be required to reapply and

comply with the requirements for licensure at the time of the reapplication. To reapply, you must submit a

new application and you will be required to comply with the licensing requirements and pay fees that are in

effect at the time you submit your new application.

12/10

7) Q: Will any of the documents that supplemented my first application be saved in case I need to reapply?

A: No. When you reapply, you will need to again provide us with documentation.

8) Q: Will the application fee that I paid with my first application carry over to cover the application fee for my new

application?

A: No. You will be required to again pay the non-refundable application fee.

9) Q: If my application has not been destroyed does this mean that it has not yet been deemed "abandoned?"

A: No. Simply because an application has not been destroyed does not mean that it has not been deemed

abandoned.

10) Q: If I am currently unable to complete the licensing process (eg., no continued effort), how do I prevent my

application from being abandoned?

A: You have two years to complete the licensing process. However, if you are unable to show continued effort

for two consecutive years but you still intend to complete the licensing process, you must send a written

communication to the board or program prior to the two year expiration explaining why you are unable to

complete the licensing process within two years. Your written communication shall also request approval to

complete the licensing process by a specific date after the two year expiration. You will be advised whether

your request is approved or disapproved. If disapproved, your application will be destroyed and you will need

to reapply for licensure.

11) Q: Who do I contact to find out if my application is soon to be abandoned?

A: You may contact the Licensing Branch at (808) 586-3000.

-2-

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

6) Q: Will you be providing a notice to me before my application is abandoned?

A: It is not required that we notify you before your application is abandoned. However, some boards and

Fill Online, Printable, Fillable, Blank IMPORTANT PLEASE READ CAREFULLY BEFORE SUBMITTING YOUR APPLICATION (Hawaii) Form

Related forms

Fillable IMPORTANT PLEASE READ CAREFULLY BEFORE SUBMITTING YOUR APPLICATION (Hawaii)

Fill Online, Printable, Fillable, Blank IMPORTANT PLEASE READ CAREFULLY BEFORE SUBMITTING YOUR APPLICATION (Hawaii) Form

Related forms

First 20 documents completely FREE!