Volunteer'S Certificate Renewal Application Rorm - Sample - Ohio Board Of Nursing - 2015 Page 2

Application for Volunteer Certificate (VC) Renewal In Ohio

CONTINUNING EDUCATION (CE) See additional instructions

❏

I have submitted the CE requirements to renew my certificate.

COMPLIANCE Answer Yes or No to EACH question.

The following questions apply SINCE the submission of your last renewal application OR if this is your first renewal from the date your original

☛

license application was filed. Have you been convicted of, found guilty of, pled guilty to, pled no contest to, pled not guilty by reason of insanity to,

entered an Alford plea, received treatment or intervention in lieu of conviction, or been found eligible for pretrial diversion or a similar program for

any of the following crimes? This includes crimes that have been expunged if the crime has a direct and substantial relationship to nursing practice.

ANSWER EACH QUESTION

Yes No

1a.

A felony in Ohio, another state, commonwealth, territory, province, or country? If you answer “Yes”, enter the court and case number.

❏ ❏

Court Name:___________________________________________________________Case#:_____________________________________

1b.

A misdemeanor in Ohio, another state, commonwealth, territory, province, or country? This does not include traffic violations unless they

❏ ❏

are DUI/OVI or Physical Control While Under the Influence. If you answer “Yes”, enter the court and case number.

Court Name:___________________________________________________________Case#:_____________________________________

2.

Has any board, bureau, department, agency or other body, including those in Ohio, other than this Board, in any way limited, restricted,

❏ ❏

suspended, or revoked any professional license, certificate, or registration granted to you; placed you on probation, or imposed a fine,

censure, or reprimand against you? Have you voluntarily surrendered, resigned, or otherwise forfeited any professional license, certificate,

or registration?

3.

Have you for any reason, been denied an application, issuance, or renewal for licensure, certification, registration, or the privilege of taking

❏ ❏

an examination, in any state (including Ohio), commonwealth, territory, province, or country?

4.

Have you entered into an agreement of any kind, whether oral or written, with respect to a professional license, certificate, or registration, in

❏ ❏

lieu of or in order to avoid formal disciplinary action, with any board, bureau, department, agency, or other body, including those in Ohio,

other than this Board?

5.

Have you been notified of any current investigation of you, or have you been notified of any formal charges, allegations, or complaints filed

❏ ❏

against you by any board, bureau, department, agency, or other body, including those in Ohio, other than this Board, with respect to a

professional license, certificate, or registration?

6.

Have you been found to be a mentally ill person subject to hospitalization by court order, been found to be mentally incompetent by a

❏ ❏

probate court, or been found incompetent to stand trial by a court?

7.

Are you required to register, under Ohio law, the law of another state, the U.S., or a foreign country, as a sex offender?

❏ ❏

8.

Have you been addicted to, dependent on, diagnosed with addiction, dependence or substance abuse disorder related to, or treated for

❏ ❏

addiction, abuse, dependence or substance disorder related to your use of alcohol or any chemical substance; or have you used any drugs

that are illegal or were prescription drugs used by you without a legal, valid prescription?

If you answer “Yes” to questions 1, 6, or 7, you are required to provide the Board with a written explanation of the events including the date, county,

☛

and state in which the events occurred, a certified copy of the indictment or criminal complaint, plea, or journal entry from the appropriate court(s). A

copy of the court docket or case summary does not meet this requirement.

☛ If you answer “Yes” to questions 2, 3, 4, 5, or 8, you are required to provide the Board with a written explanation and certified copies of any

documents (if applicable).

VERIFICATION Sign below on the signature line.

I am a U.S. citizen or lawfully admitted into the U.S. or I am a foreign national not living in the United States. I verify that all information on this form

is true and accurate. I am aware that misrepresentation on this application may result in disciplinary action in accordance with Section 4723.28(A)

and/or (B), ORC.

SIGNATURE

2015

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _