Form 08-4016 - Application For Registered Nurse By Endorsement - 2000 Page 2
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3EXAM AND ORIGINAL LICENSURE: Indicate where and when you took the State Board Test Pool Examination (SBTPE)
or National Council Licensure Examination (NCLEX).
Dates Taken
State
License Number
Year Granted
Expiration Date
ADDITIONAL LICENSES:
List all other nursing licenses or permits which you hold or have held. Provide the state license number if available, and
status (current, lapsed, etc.). Indicate last name on license, if different than current name.
Expiration Date/Status
State/Province
License No., If Known
(Active, Expired, Probation, etc.)
FOREIGN LICENSED:
q
q
From Canada:
Have you taken CNATS?
Yes
No
Province:
Dates Taken:
If taken after June 1992, you are not eligible for a license by endorsement and must take the NCLEX exam.
If a graduate of a Foreign School of Nursing, have you taken the Commission on Graduates of Foreign Nursing Schools
q
q
Examination?
Yes
No
Certificate Number:
Dates Taken:
DISCIPLINARY HISTORY: The following must be answered pursuant to 12 AAC 44.305(a)(1)(D) and AS 08.68.270:
1.
Has your professional license in any state or country ever been denied, revoked, suspended,
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stipulated, on probation, or been subject to any other restriction or disciplinary action? .......
Yes
No
2.
Have you ever been convicted of a felony or other criminal offense other than a minor
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traffic violation? .............................................................................................................
Yes
No
3.
Have you ever been the subject of an inquiry or under investigation by any state board
or other licensing agency concerning a violation or alleged violation of any state regulation,
statute or law, for any violation or alleged violation of the Nursing Practice Act, or
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unprofessional or unethical conduct? ..............................................................................
Yes
No
PERSONAL HISTORY: The following must be answered pursuant to 12 AAC 44.305(a)(1)(C) and AS 08.68.270:
4.
Within the past five years, have you been or are you being treated for emotional
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or mental illness, drug addiction, use or misuse of a chemical substance?.........................
Yes
No
5.
Within the past five years, have you been or are you addicted to, excessively used,
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or misused alcohol, narcotics, barbiturates or habit-forming drugs?....................................
Yes
No
6.
Within the past five years, have you had or do you have a physical disability or
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physical illness which may impair or interfere with your ability to practice nursing? .............
Yes
No
If you answered “Yes” to any of the above questions, please explain dates and circumstances on a separate
piece of paper, and send any supporting documents that are applicable (court records, etc.).
08-4016 (Rev. 8/00)
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