Volunteer'S Certificate Renewal Application Rorm - Sample - Ohio Board Of Nursing - 2015

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Application Instructions for Volunteer Certificate (VC) Renewal In Ohio
DETAILED INSTRUCTIONS:
• Complete the entire application, sign, and return to the Board.
• Incomplete applications will be returned.
CONTINUING EDUCATION (CE):
You are required to complete 24 contact hours of continuing education to renew your Volunteer Certificate.
IMPORTANT
• Your certificate will not be renewed until a completed application is received and processed by the Board.
• Your application is considered incomplete if all sections have not been completed and/or you have not
signed your application.
• You cannot practice nursing in Ohio without a current, valid volunteer certificate.
• You may verify your certificate status online by following the instruction page on the License/Certificate
Verification link on the Board’s website at:
CHANGE IN SOCIAL SECURITY NUMBER:
Skip this section if you have no changes. Make changes as applicable.
If you have changed or obtained a new Social Security Number, please provide both your old AND new numbers.
Old________________________________________
New____________________________________________
Your social security number is required by state and federal law for purposes of child support enforcement (ORC 3123.50, 42 U.S.C. Section 666), reporting to the National
Practitioner Data Bank (Public Law 100-93, Sec. 1921 of the Social Security Act, as amended; 45 C.F.R. pt. 60); reporting to law enforcement authorities for
investigative/law enforcement purposes in compliance with ORC 4723.28, and/or as otherwise required by state and federal law.
CORRECTIONS & NAME/ADDRESS CHANGE:
Skip this section if you have no changes. Make changes as applicable.
You must submit a certified record of a name change (i.e. marriage certificate/abstract, divorce decree/dissolution, court record indicating
the name change) within thirty days of the change. Certified court documents can be obtained from the court where the original record was
filed. Photocopies or notarized copies are not acceptable for a name change.
Last Name_______________________________________________________________________________________________________________________
First, Middle Name________________________________________________________________________________________________________________
Address_________________________________________________________________________________________________________________________
City_________________________________________________________________State________________________________Zip____________________
County__________________________________________________Telephone_____________________________________________
Email_________________________________________________________________________________________________________
VERIFICATION: You must sign this Reactivation/Reinstatement application.
COMPLETE APPLICATION ON BACK OF THIS FORM
2015

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