Fillable - Certified Nursing Assistant Licensure By Endorsement Application (Florida)

Fill Online, Printable, Fillable, Blank - Certified Nursing Assistant Licensure By Endorsement Application (Florida) Form

Use Fill to complete blank online FLORIDA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

- Certified Nursing Assistant Licensure By Endorsement Application (Florida)

On average this form takes 45 minutes to complete

The - Certified Nursing Assistant Licensure By Endorsement Application (Florida) form is 20 pages long and contains:

  • 1 signature
  • 102 check-boxes
  • 128 other fields

Country of origin: US
File type: PDF

BROWSE FLORIDA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page2of14
Requests to withdraw must be made in writing. The request must be received prior to the board considering licensure.
1. PERSONAL INFORMATION
Certified Nursing Assistant
Licensure by
Endorsement Application
Board of Nursing
P.O. Box 6330
Tallahassee, FL 32314-6330
Fax: 850-617-6460
Email: MQA.CNA@flhealth.gov
Name: _______________________________________________________________________ Date of Birth: ______________
Last/Surname First Middle MM/DD/YYYY
___________________________________________________ _______ __________________________________
Street/P.O. Box Apt. No. City
________________________________ ________ ___________________ _________________________________
State ZIP Country Home/Cell Telephone (Input without dashes)
Physical Location: (Required if mailing address is a P.O. Box- This address will be posted on the Department of Health’s website.)
___________________________________________________ _______ __________________________________
Street Apt. No. City
________________________________ ________ ___________________ _________________________________
State ZIP Country Work/Cell Telephone (Input without dashes)
EQUAL OPPORTUNITY DATA:
We are required to ask that you furnish the following information as part of your voluntary compliance with 41 CFR Part 60-3-
Uniform Guidelines on Employee Selection Procedure (1978); 43 FR 38295 and 38296 (August 25, 1978). This information is
gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure.
Gender: Male Race: Native Hawaiian or Pacific Islander Hispanic or Latino White
Female American Indian or Alaska Native Black or African American Asian
Two or More Races
Email Notification: To be notified of the status of your application by email check the “Yes” box and fill in your email address on the line
provided. If you choose to be notified via email you will be responsible for checking your email regularly and updating your email
address with the board office.
Yes No Email Address: ____________________________________________________
Under Florida law, email addresses are public records. If you do not want your email address released in response to a public records
request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing.
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page3of14
2. SOCIAL SECURITY DISCLOSURE
This information is exempt from public records disclosure.
Pursuant to Title 42 United States Code § 666(a)(13), the department is required and authorized to collect Social
Security Numbers relating to applications for professional licensure. Additionally, section (s.) 456.013(1)(a),
Florida Statutes (F.S.), authorizes the collection of Social Security numbers as part of the general licensing
provisions.
Last Name: _____________________________________________________________
First Name: _____________________________________________________________
Middle Name: ___________________________________________________________
Social Security Number: __________________________________________________
(Input without dashes)
Social Security Information- * Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary
unless specifically required by federal statute. In this instance, Social Security numbers are mandatory pursuant
to Title 42 United States Code,
§ 653 and 654; and s. 456.013(1), 409.2577, and 409.2598, F.S. Social Security
numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to
ensure compliance with child support obligations. Social Security numbers must also be recorded on all
professional and occupational license applications and will be used for license identification pursuant to Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act. 104 Pub. L. Section 317).
Clarification of the SSA process may be reviewed at www.ssa.gov or by calling 1-800-772-1213.
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page4of14
Name: _____________________________________________
3. APPLICANT BACKGROUND
A. List any other name(s) by which you have been known in the past. Attach additional sheets if necessary.
_______________________________________________________________________________________
B. What name(s) did you use when you received your education? ____________________________________
_____________________________________________________________________________________
_
C. What name did you use when you were first licensed? ___________________________________________
D. Have you ever applied for Certified Nursing Assistant (CNA) licensure in Florida? Yes No
If “Yes,” c
omplete the following:
Application Method Date (MM/DD/YYYY)
Examination Endorsement
Examination Endorsement
E. Have you ever held a CNA license in Florida? Yes No
If “Yes,” list the date the license was issued: ______
_______
MM/DD/YYYY
F. Do you hold, or have you ever held a license to practice as a CNA or any other health-related license(s)?
Yes No
G. List all health-related licenses (active, inactive or lapsed).
License
Type
License # State/Country
Original Date
Issued
(
MM/DD/YYYY
)
Expiration
Date
(
MM/DD/YYYY
)
Status of License
The board requires verification of licensure from a state where you have a current active license. If you
do not hold an active CNA license in another state, you would need to apply to take the examination
through Prometric at https://www.prometric.com.nurseaide.fl.
Office staff will attempt to complete verifications online. If unavailable online or if the online
verification lacks sufficient detail, you will be required to request an official verification.
Your out-of-state certificate must be Clear/Active and in good standing.
4. DISASTER
Would you be willing to provide health services in special needs shelters or to help staff disaster medical
assistance teams during times of emergency or major disaster? Yes No
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page5of14
Name: _____________________________________________
This information is exempt from public records disclosure
5. HEALTH HISTORY
Physical and Mental Health Disorders Impacting Ability to Practice
A. During the last two years, have you bee
n treated for or had a recurrence of a diagnosed physical or mental
disorder that impaired or would impair your ability to practice? Yes No
B. In the last two years, have you been admitted or referred to a hospital, facility or impaired practitioner program
for treatment of a diagnosed mental or physical disorder that impaired your ability to practice? Yes No
Substance-Related Disorders Impacting Ability to Practice
C. During the last five years, have you been treated for
or had a recurrence of a diagnosed substance-related
(alcohol or drug) disorder that impaired or would impair your ability to practice? Yes No
D. During the last five years, were you admitted or directed into a program for the treatment of a diagnosed
substance-related (alcohol or drug) disorder or, if you were previously in such a program, did you suffer a
relapse? Yes No
E. During the last five years, have you been enrolled in, required to enter, or participated in any substance-
related (alcohol or drug) recovery program or impaired practitioner program for treatment of drug or alcohol
abuse? Yes No
If a “Yes” response was provided to any of the questions in this section, provide the following documents
directly to the board office:
A letter from a Licensed Health Care Practitioner, who is qualified by skill and training to address the
condition identified, which explains the impact the condition may have on the ability to practice the
profession with reasonable skill and safety. The letter must specify that the applicant is safe to practice
the profession without restrictions or specifically indicate the restrictions that are necessary.
Documentation provided must be dated within one year of the application date.
A written self-explanation, identifying the medical condition(s) or occurrence(s); and current status
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page6of14
Name: _____________________________________________
6. DISCIPLINE HISTORY
A. Have you ever been denied or is there now any proceeding to deny your application for any health care
license to pra
ctice in Florida or any other state, jurisdiction, or country? Yes No
B. Have you ever had any disciplinary action taken against your
license to practice any health care related
profession by the licensing authority in Florida or in any other state, jurisdiction, or country? Yes No
C. Have you ever surrendered a license to practice any health care related profession in Florida or any other
state, jurisdict
ion, or country while any such disciplinary charges were pending against you? Yes No
D. Do you have any disciplinary action pending against you? Yes No
If you respo
nded “Yes” to questions in this section, complete the
following:
Name of Agency State
Action Date
(MM/DD/YYYY)
Final Action
Under
Appeal?
Y
N
Y N
Y N
If you responded “Yes” to questions in this section, you must provide the following:
A written self-explanation, describing
in detail the circumstances surrounding the disciplinary action.
A copy of the Administr
ative Complaint and Final Order.
Three current (written in the last ye
ar) professional Letters of Recommendation.
7. CRIMINAL HISTORY
A. Have you ever
been convicted of, or entered a plea of guilty, nolo contendere, or no contest to any crime in
any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if
adjudication was withheld.
Reckless driving, driving while license suspended or revoked (DWSLR), dr
iving under the influence (DUI) or
driving while impaired (DWI) are not minor traffic offenses for purposes of this question. Yes No
B. Have you ever
had any records sealed pursuant to s. 943.059, F.S., or other state’s applicable statute?
Yes No
C. Have you ever
been adjudicated delinquent? Yes No
If you responded “Yes” in
this section, complete the following:
Offense Jurisdiction
Date
(MM/DD/YYYY)
Final Disposition
Under
Appeal?
Y
N
Y N
Y
N
If you responded “Yes,” you must provide the following:
Self-Explanation, describing in detail the circumstances surroundi
ng each offense; including date, city
and state, charges and final results.
Final Dispositions and Arrest Records for all offenses. The Clerk of the Court i
n the arresting
jurisdiction will provide you with these documents. Unavailability of these documents must come in the
form of a letter from the Clerk of the Court.
Completion of Sentence Documents. You may o
btain documents from the Department of Corrections.
The report must include the start date, end date, and that the conditions were met.
Three current (written within the las
t year) professional Letters of Recommendation.
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page7of14
Name: _____________________________________________
8. C
RIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS
IMPORTANT NOTICE: Applicants for licensure, certification, or registration and candidates for examination may
be excluded from licensure, certification, or registration if their felony convictions fall into certain timeframes as
established in s. 456.0635(2), F.S.
1. Have you been convicted of, or entered a plea of guilty or nolo contendere, regardless of adjudication, to a
felony under chapter (ch.) 409, F.S. (relating to social and economic assistance), ch. 817, F.S. (relating to
fraudulent practices), ch. 893, F.S. (relating to drug abuse prevention and control) or a similar felony
offense(s) in another state or jurisdiction? Yes No
If you responded “No” to the question above, skip to question 2.
a. If “Yes” to 1, for the felonies of the first or second degree, has it been more than 15 years from the date of
the plea, sentence, and completion of any subsequent probation? Yes No
b. If “Yes” to 1, for the felonies of the third degree, has it been more than ten years from the date of the plea,
sentence, and completion of subsequent probation? (This question does not apply to felonies of the third
degree under s. 893.13(6)(a), F.S.). Yes No
c. If “Yes” to 1, for the felonies of the third degree under s. 893.13(6)(a), F.S., has it been more than five
years from the date of the plea, sentence, and completion of any subsequent probation? Yes No
d. If “Yes” to 1, have you successfully completed a drug court program that resulted in the plea for the felony
offense being withdrawn or the charges dismissed? (If “Yes,” provide supporting documentation).
Yes No
2. Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, to a
felony under 21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396 (relating to public health, welfare, Medicare
and Medicaid issues)? Yes No
If you responded “No” to the question above, skip to question 3.
a. If “Yes” to 2, has it been more than 15 years before the date of application since the sentence and any
subsequent period of probation for such conviction or plea ended? Yes No
3. Have you ever been terminated for cause from the Florida Medicaid Program pursuant to s. 409.913, F.S.?
Yes No
If you responded “No” to the question above, skip to question 4.
a. If you have been terminated but reinstated, have you been in good standing with the Florida Medicaid
Program for the most recent five years? Yes No
4. Have you ever been terminated for cause, pursuant to the appeals procedures established by the state, from
any other state Medicaid program? Yes No
If you responded “No” to the question above, skip to question 5.
a. Have you been in good standing with a state Medicaid program for the most recent five years?
Yes No
b. Did termination occur at least 20 years before the date of this application? Yes No
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page8of14
Name: _____________________________________________
5. Are you currently listed on the United
States Department of Health and Human Services’ Office of the
Inspector General’s List of Excluded Individuals and Entities (LEIE)? Yes No
a. If you responded “Yes” to the question above, are you listed because you defaulted or are delinquent on
a st
udent loan? Yes No
b. If you responded “Yes” to question 5.a., is the student loan default or delinquency the only reason you are
listed on the
LEIE? Yes No
If you responded “Yes” to any of the questions in this section, you must provide the following:
A written explanation fo
r each q
uestion including the county and state of each termination or conviction,
date of each termination or conviction, and copies of supporting documentation.
Supporting documentation including
court dispositions or agency orders where applicable.
9. LIVESCAN PRIVACY STATEMENT
I have been provided and read the statement from the Florida Department of Law Enforcement regarding the
shar
ing, retention, privacy and right to challenge incorrect criminal history records and the “Privacy Statement”
document from the Federal Bureau of Investigation. (Found in the forms following this application).
The board will not receive your Livescan results if you do no
t confirm the above statement by checking the box.
Electronic Fingerprinting: (Required for ALL applicants)
All applicants, including out-of-state applicants, are required to submit their fingerprints electronically. The Department of
Health accepts electronic fingerprinting offered by Livescan service providers that are approved by the Florida Department
of Law Enforcement. For a list of approved vendors, visit our website at: http://www.flhealthsource.gov/background-
screening/.
Typically background results submitted by Livescan are received by the board within 24-72 hours of being processed. The
board’s ORI number is EDOH0380Z. The board cannot accept hard fingerprint cards or results. All results must be
submitted electronically by the Livescan service provider.
Livescan screenings performed by a Florida Police or
Sheriff’s Department require that you login to the FDLE Civil
Applicant Payment System (CAPS) at https://caps.fdle.state.fl.us and pay a fee before your results will be released to our
office.
The Florida Department of Health retains fingerprints on any applicant in the Care Provider Clearinghouse. One of the
requirem
ents for your Livescan to be retained in the Care Provider Clearinghouse is a photograph must be taken by the
Livescan service provider at the time of fingerprinting. Your background screening results will be retained for five years.
You will be notified when your retention date is approaching and will be provided with instructions on how to retain your
fingerprints to avoid having to submit a new background screening
Applicants needing hard fingerprint cards can request them via email at MQA.BackgroundScre
en@flhealth.gov. Request
must include the current mailing address you want the cards mailed to. To find providers who offer this service go to
http://www.flhealthsource.gov/bgs-providers. Click on “Out of State/International” section of the map.
Documentationforsection7and8mustbe
senttotheBackgroundScreeningUnitat
MQA.BackgroundScreen@flhealth.govor
mailedto:
BackgroundScreeningUnit
FloridaDepartmentof
Health
4052BaldCypressWay,BinBSU‐01
Tallahassee,FL32399
Documentationforsections5and6mustbe
senttotheboardofficeat
MQA.Nursing@flhealth.govormailedto:
BoardofNursing
4052BaldCypressWayBinC‐02
Tallahassee,FL32399‐3252
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page9of14
Name: _____________________________________________
10. APPLICANT SIGNATURE
I, the undersigned, state that I am the person refe
rred to in this application for licensure in the state of Florida.
I recognize that providing false information may result in disciplinary action against my license or criminal penalties
pursuant to s. 456.067, 775.083, F.S.
I further state that I have read and understand ch. 464, F.S., and Rule ch. 64B9, Florida Administrative Code (F.A.C.)
as they pertain to the practice of nursing (Note: A current copy of ch. 464 and rule ch. 64B9 may be obtained online at
http://www.floridasnursing.gov).
Florida law re
quires me to immediately inform the board of any material change in any circumstances or condition
stated in the application which takes place between the initial filing and the final granting or denial of the license and
to supplement the information on this application as needed.
I will comply with all requirements for licensure renewal, including in-service training hours.
Section 456.013(1)(a), F.S., provides that an incomplete application shall expire one year after the initial filing with the
department.
Applicant Signature ______________________________________________________ Date ________________
You may print this application and sign it or sign digitally. MM/DD/YYYY
click to sign
signature
click to edit
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page10of14
FLORIDA DEPARTMENT OF LAW ENFORCEMENT
NOTICE FOR ALL APPLICANTS SUBMITTING FINGERPRINTS WHERE CRIMINAL REOCRDS RESULTS
WILL BECOME PART OF THE CARE PROVIDER BACKGROUND SCREEING CLEARINGHOUSE
NOTICE OF:
SHARING OF CRIMINAL HISTORY RECORD INFORMATION WITH SPECIFIED AGENCIES,
RETENTION OF FINGERPRINTS,
PRIVACY POLICY, AND
RIGHT TO CHALLENGE AN INCORRECT CRIMINAL HISTORY RECORD
This notice is to inform you that when you submit a set of fingerprints to the Florida Department of Law
Enforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal history
records that may pertain to you, the results of that search will be returned to the Care Provider Background
Screening Clearinghouse. By submitting fingerprints, you are authorizing the dissemination of any state and
national criminal history record to be employed, licensed, work under contract, or serve as a volunteer,
pursuant to the National Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes.
“Specified agency” means the Department of Health, the Department of Children and Family Services, the
Division of Vocational Rehabilitation within the Department of Education, the Agency for Health Care
Administration, the Department of Elder Affairs, the Department of Juvenile Justice, and the Agency for Person
with Disabilities when these agencies are conducting state and national criminal history background screening
on persons who provide care for children or persons who are elderly or disabled. The fingerprints submitted will
be retained by FDLE and the Clearinghouse will be notified if FDLE receives Florida arrest information on you.
Your Social Security Number (SSN) is needed to keep records accurate because other people may
have the same name and birth date. Disclosure of your SSN is imperative for the performance of the
Clearinghouse agencies’ duties in distinguishing your identity from that of other persons whose
identification information may be the same or similar to yours.
Licensing and employing agencies are allowed to release a copy of the state and national criminal record
information to a person who requests a copy of his or her own record if the identification of your record was
based on submission of the person’s fingerprints. Therefore, if you wish to review your record, you may
request that the agency that is screening the record provide you with a copy. After you have reviewed the
criminal history record, if you believe it is incomplete or inaccurate, you may conduct a personal review as
provided in S. 943.056, F.S., and Rule 11C-8.001, F.A.C. If national information is believed to be in error, the
FBI should be contacted at 304-625-2000. You can receive any national criminal history record that may
pertain to you directly from the FBI, pursuant to 28 CFR Sections 16.30-16.34. You have the right to obtain a
prompt determination as to the validity of your challenge before a final decision is made about your status as
an employee, volunteer, contractor, or subcontractor.
Until the criminal history background check is completed, you may be denied unsupervised access to children,
the elderly, or persons with disabilities.
The FBI’s Privacy Statement follows on a separate page and contains additional information.
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page11of14
US Department of Justice
Federal Bureau of Investigation
Criminal Justice Information Services Division
PRIVACY STATEMENT
Authority: The FBI’s acquisition, preservation and exchange of information requested by this form is generally
authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include
numerous Federal statutes, hundreds of State statutes pursuant to Pub. L.92-544, Presidential executive
orders, regulations and/or orders of the Attorney General of the United States, or other authorized authorities.
Examples include, but are not limited to: 5 U.S.C. 9101; Pub.L.94-29; Pub.L.101-604; and Executive Orders
10450 and 12968. Providing the requested information is voluntary; however, failure to furnish the information
may affect timely completion of approval of your application.
Social Security Account Number (SSAN). Your SSAN is needed to keep records accurate because other
people may have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a),
the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what
statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also
asks Federal Agencies to use this number to help identify individuals in agency records.
Principal Purpose: Certain determinations, such as employment, security, licensing and adoption, may be
predicated on fingerprint-based checks. Your fingerprints and other information contained on (and along with)
this form may be submitted to the requesting agency, the agency conducting the application investigation,
and/or FBI for the purpose of comparing the submitted information to available records in order to identify other
information that may be pertinent to the application. During the processing of this application, and for as long
hereafter as may be relevant to the activity for which this application is being submitted, the FBI (may disclose
any potentially pertinent information to the requesting agency and/or to the agency conducting the
investigation. The FBI may also retain the submitted information in the FBI’s permanent collection of
fingerprints and related information, where it will be subject to comparisons against other submissions received
by the FBI. Depending on the nature of your application, the requesting agency and/or the agency conducting
the application investigation may also retain the fingerprints and other submitted information for other
authorized purposes of such agency(ies).
Routine Uses: The fingerprints and information reported on this form may be disclosed pursuant to your
consent, and may also be disclosed by the FBI without your consent as permitted by the Federal Privacy Act of
1974 (5 USC 552a(b)) and all applicable routine uses as many be published at any time in the Federal
Register, including the routine uses for the FBI Fingerprint Identification Records System (Justice, FBI-009)
and the FBI’s Blanket Routine Uses (Justice/FBI-BRU). Routine uses include, but are not limited to, disclosure
to: appropriate governmental authorities responsible for civil or criminal law enforcement counterintelligence,
national security or public safety matters to which the information may be relevant; to State a local
governmental agencies and nongovernmental entities for application processing as authorized by Federal and
State legislation, executive order, or regulation, including employment, security, licensing, and adoption
checks; and as otherwise authorized by law, treaty, executive order, regulation, or other lawful authority. If
other agencies are involved in processing the application, they may have additional routine uses.
Additional information: The requesting agency and/or the agency conducting the application investigation will
provide additional information to the specific circumstances of this application, which may include identification
of other authorities, purposes, uses and consequences of not providing requested information. In addition, any
such agency in the Federal Executive Branch has also published notice.
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page12of14
BoardofNursing
ElectronicFingerprinting
Take this form with you to the Livescan service provider. Check the service provider’s
requirements to see if you need to bring any additional items.
Background screening results are obtained from the Florida Department of Law
Enforcement and the Federal Bureau of Investigation by submitting a fingerprint scan using the Livescan method.
You can find Livescan service providers at: http://www.flhealthsource.gov/background-screening/.
Failure to submit background screening will delay your application.
Applicants may use any Livescan service provider approved by the Florida Department of Law Enforcement to
submit their background screening to the department.
If you do not provide the correct Originating Agency Identification (ORI) number to the Livescan service provider,
the board office will not receive your background screening results.
You must provide accurate demographic information to the Livescan service provider at the time your fingerprints
are taken, including your Social Security number (SSN).
The ORI number for the Board of Nursing is EDOH0380Z.
Typically background screening results submitted through a Livescan service provider are received by the board
within 24-72 hours of being processed.
If you obtain your Livescan from a service provider who does not capture your photo you may be required to be
reprinted by another agency in the future.
Name:
___________________________________________________________________ SSN#: __________________________
Aliases: ____
______________________________________________________________________________________
Address: ____________________________________________________________________ Apt. Number: _________
City: _________________________________________ State: _____________________________ ZIP: ____________
Date of Birth: ________________ Place of Birth: _________________________________________________________
MM/DD/YYYY
Weight: ____________ Height: ______________ Eye Color: _________________ Hair Color: _____________________
Race: ___________ Sex: ____________
(W-White/Latino(a); B-Black; A- Asian; NA-Native American; U-Unknown) (M= Male; F=Female)
Citizenship: _______________________________
Transaction Control Number (TCN#): ___________________________________________________________________
(This will be provided to you by the Livescan service provider.)
Keep this form for your records.
-
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page13of14
Office staff will attempt to complete verifications online. If unavailable online or if the online verification lacks
sufficient detail, you will be required to request an official verification.
Complete verifications must be mailed directly from the licensing agency to:
BoardofNursing
4052BaldCypressWayBinC‐02
Tallahassee,FL32399‐3252
BoardofNursingLicenseVerificationRequest
Part I: To be completed by applicant (Florida requires verification of an active license in another state.)
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
Name original license was issued under: _________________________________________________________
License Number: _____________________________________ State: _________________________________
I hereby authorize release of any information regarding my licensure status to the Florida Board of Nursing.
Applicant Signature: _________________________________________________ Date: __________________
MM/DD/YYYY
Part II: To be completed by state licensing agency
All verifications must be in English and include the following criteria:
*
Typed on an official state form or letterhead
*
Include an official board seal
*
Signature and title of state board official
The following information must be included in all verifications:
*
Licensee name * License number * State or jurisdiction of licensure
*
Licensure status * Is license in good standing?
*
Date of issuance/expiration
*
Licensure method (examination, grandfathering, reciprocity/endorsement)
*
Has this license ever been encumbered (denied, revoked, suspended, surrendered, limited, placed
on probation)?
*
If this license has ever been encumbered, please provide certified copies of documentation
regarding the action with the completed license verification.
DH‐MQA5022,Revised6/2020,Rule64B9‐15.0035,F.A.C. Page14of14
Complete verifications must be mailed directly from the verifying agency to:
BoardofNursing
4052BaldCypressWayBinC‐02
Tallahassee,FL32399‐3252
BoardofNursingEmploymentVerificationRequest
Who needs to use this form?
Applicants who are licensed in states that do not list a current licensure status on the Nurse
Registry website.
Applicants licensed in states that do not maintain employment records for the purpose of validating
an “active” licensure status.
Part I: To be completed by applicant (Complete this section and submit a copy to each place you were
employed during the last 24 months. Employment verification must be from the state from which you
are Endorsing.)
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
Name of hospital or agency: ___________________________________________________________________
I hereby authorize release of any information regarding my employment status with your facility to the Florida Board of
Nursing.
Applicant Signature: _________________________________________________ Date: __________________
MM/DD/YYYY
Part II: To be completed by employer- All verifications must be in English and mailed directly from the
hospital personnel office or agency/employer and must include the following:
*
Typed on official agency letterhead with an original signature
*
Applicant name
*
Applicant’s Social Security Number
*
Indicate level of licensure while employed (Certified Nursing Assistant)
*
Position title while employed
*
Place of employment
*
Address of employer (including mailing address, city, state, ZIP, country)
*
Employer’s telephone number (including area code)
*
Start and end dates of employment (month and year)
*
Eligible for rehire? (Yes/No) If not eligible for rehire, please provide written details
*
Printed name of verifying agent
*
Signature of verifying agent and date completed

Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

- Certified Nursing Assistant Licensure By Endorsement Application (Florida)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 24 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document