Form 08-4067 - Application For Reinstatement Of Nursing License
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3NUR
STATE OF ALASKA
FOR OFFICE USE ONLY
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
BOARD OF NURSING
STATE OFFICE BUILDING
333 WILLOUGHBY AVENUE, 9TH FLOOR
P.O. BOX 110806, JUNEAU, ALASKA 99811-0806
Fax (907) 465-2974
E-mail: license@dced.state.ak.us
If your last name begins with A – K, contact (907) 465-2544
If your last name begins with L – Z, contact (907) 465-2648
APPLICATION FOR REINSTATEMENT OF NURSING LICENSE
$265.00 fee for reinstatement of lapsed license (includes $215.00 license fee and
$50.00 application fee). Make check payable to the STATE OF ALASKA.
Alaska Statute 08.68.251. Lapsed Licenses. (a) A lapsed license may be reinstated if it has not remained lapsed for more
than five years by payment of the license fees for the current renewal period and the penalty fee. The person seeking
reinstatement shall meet the continuing competency requirements of the board.
(b) If a license is lapsed for more than five years
(1) the board shall require the applicant to complete a course of study approved by the board or to pass an examination
prescribed by the board, and to pay the fees prescribed by this chapter; or
(2) if the board determines that the person applying for reinstatement was actively employed in nursing in another state
during the time that the license has lapsed in this state, the license that has lapsed may be reinstated by payment of fees as
required by (a) of this section.
The board will renew a license that has lapsed for at least one year but not more than five years upon receipt of the current
renewal fees, all applicable penalty fees, copies of all continuing education certificates that would have been required to maintain
a current license for the entire period that the license has been lapsed (12 AAC 44.900(d)).
CONTINUED COMPETENCY REQUIREMENTS
Completion of TWO of the following three methods of continued competency must be reported to the Board of Nursing before
a license can be renewed or reinstated:
1.
320 hours of nursing employment
2.
30 contact hours of continuing education in nursing
3.
30 hours of volunteer professional activities in nursing
(Submit copies of continuing education credits for entire time lapsed. See attached for employment and professional
activities verification forms.)
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RN
LPN
Alaska License Number:
Name:
Mailing Address:
City:
State:
Zip Code:
Social Security No.:
Date of Birth:
Telephone No.:
Required by AS 08.01.060. (The department is not authorized to issue a license to an applicant unless the person’s Social Security
Number has been provided.)
List all states/licensing jurisdictions in which you hold or have held a nursing license/permit to practice:
Jurisdiction
License Number (if known)
Expiration Date
FOR OFFICE USE ONLY
License No.
Type:
Expiration:
Archive Request:
08-4067 (Rev. 8/00)
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