Form 08-4067 - Application For Reinstatement Of Nursing License Page 2
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1
2
3ADDITIONAL EDUCATION
List any education program or continuing education courses taken during the past two years of the lapsed period. Attach
additional sheets if necessary.
Name of Sponsor
Subject
Dates Attended
EMPLOYMENT
List nursing employment during the last five years, beginning with the most recent employer. Mail Verification of Employment
form to most recent employer listed below. If you have not been employed in the last five years, list last employer and date of
employment:
Address
Dates
Employer
Position
From
To
(Complete address including zip code)
NOT EMPLOYED PAST FIVE YEARS
o
o
If you have not been employed, have you completed a refresher course in the past five (5) years?
Yes
No
If “Yes,” attach a record of completion of the course, or have the educational institution submit documentation, and list the
program below:
Program
Address
Dates Attended
Please contact the Executive Administrator for the Board of Nursing at (907) 269-8161 for refresher course information and
determination if refresher course is needed, or write to the Alaska Board of Nursing, 3601 C Street, Suite 722, Anchorage, Alaska
99503, or the Licensing Examiner at the Juneau address and telephone number listed on the previous page.
DISCIPLINARY HISTORY: The following must be answered pursuant to AS 08.68.270:
1.
Has your professional license in any state or country ever been denied, revoked, suspended,
o
o
stipulated, on probation, or been subject to any other restriction or disciplinary action?.................
Yes
No
2.
Have you ever been convi cted of a felony or other criminal offense other than a minor
o
o
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
o
o
unprofessional or unethical conduct?........................................................................................
Yes
No
08-4067 (Rev. 8/00)
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