Form 08-4067 - Application For Reinstatement Of Nursing License Page 3
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3PERSONAL HISTORY: The following must be answered pursuant to AS 08.68.270:
4.
Within the past five years, have you been or are you being treated for emotional
o
o
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,
o
o
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
o
o
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.). All information provided with
this application will be considered “public” unless required to remain confidential by state and federal law.
CONTINUED COMPETENCY
Compliance with continued competency requirements is necessary for reinstatement of your license. Nurses whose licenses
have been lapsed for more than five years may need to take a refresher course as determined by the Executive Administrator.
Indicate the sections with which you have complied in the two years preceding this request for reinstatement and provide
documentation. You must complete two of the items in order to be reinstated.
1. 320 hours of nursing employment. Mail the Verification of Employment form to your last employer in a nursing
capacity.
2. 30 contact hours of continuing nursing education. Submit certified copies of certificates of completion or proof
of attendance at CE offerings. (The number of hours you must verify depends upon how long your license has
lapsed.)
3. 30 hours of professional activities. Mail Professional Activities Verification form to organization where you
completed professional activities.
APPLICATION PROCESS
From the date we receive your application, the processing time for reinstatement will take four to six weeks. This time frame
includes review time by the licensing examiner, notice to you if additional documents are needed, and a final review by the
executive administrator of your application once all supporting documents are received. You can assist in reducing the time it
takes to process your application by making sure you have properly completed the form and have arranged for all supporting
documents to be sent as quickly as possible. Since your license has lapsed, this application cannot be processed like a
renewal, which takes less time to process.
I HEREBY CERTIFY and declare that I am the person referred to in the foregoing application and that the information contained
in this application is true and correct to the best of my knowledge. I further certify that all credentials supplied by me are true
and correct. I understand that any false information or falsification of credentials may result in failure to obtain a license to
practice nursing in the State of Alaska.
+
SIGN HERE
Signature of Applicant
SUBSCRIBED AND SWORN before me, a Notary Public in and for the State of
this
day of
, 20
.
+
SIGN HERE
Signature of Notary Public
NOTARY SEAL
My Commission Expires:
08-4067 (Rev. 8/00)
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