Application For Licensure As A Registered Nurse By Reciprocity Information And Instructions (Page 5 of 8) in pdf

If necessary, continue on another sheet of paper. Please be sure not to omit any states or licenses.

Omissions will delay the processing of your application.

If you answer “yes” to any of the following questions, the Board must evaluate your

QUESTIONS:

compliance with the Good Moral Character (GMC) licensure requirement. This evaluation must be completed

to determine your qualifications for initial licensure in Massachusetts. Prior to submitting this application,

review the Board’s Licensure Policy 00-01: Determination of Good Moral Character Compliance and the

Determination of Good Moral Character Compliance Information Sheet. Submit all required documentation to

the Board as directed. Failure to answer all questions truthfully may result in a five year exclusion from

licensure.

YES NO

Answer all questions truthfully and accurately.

Has any disciplinary action ever been taken against you by a professional and/or trade licensing/certification board

located in the United States, the District of Columbia, U.S. territory, or any country/foreign jurisdiction, including

removal from a long-term care nurse aide registry program?

Are you the subject of pending disciplinary action by a professional and/or trade licensing/certification board located

in the United States, the District of Columbia, U.S. territory, or any country/foreign jurisdiction?

Have you ever applied for, and been denied, a professional and/or trade license/certification in the United States, the

District of Columbia, U.S. territory, or any other country/foreign jurisdiction?

Have you ever surrendered or resigned a professional and/or trade license/certificate in the United States, the

District of Columbia, U.S. territory, or any other country/foreign jurisdiction?

Have you ever been convicted of a felony or misdemeanor in the United States, the District of Columbia, U.S.

territory, or any other country/foreign jurisdiction?

Are you the subject of any pending or open criminal case (s) or investigation(s), (including for any felony or

misdemeanor) in a jurisdiction in the United States, the District of Columbia, U.S. territory, or any country/foreign

jurisdiction?

If you have answered “yes” to any of the above questions, the Board may deny your

application for licensure. Denial of licensure by the Board is considered a disciplinary action

and may have consequences before other professional licensing and certifying boards,

including any licenses or certifications you may currently hold.

If you answered “yes” to question #

, DO NOT submit this application. In accordance with

Licensure Policy 00-01: Determination of Good Moral Character Compliance the Board will

deny licensure if the applicant has failed to fulfill all requirements imposed by a

licensure/certification body or if all criminal matters have not been closed for at least one (1)

year.

Continue to next page.

Revised January 2015

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