11. Have you ever submitted an application for permission to enroll in clinical to LSBN?
YES________ NO ____If yes, when? (MM/YYYY) ___________________________________
RN School(s) approved by LSBN to attend
Program ________________________________ STU # (issued by LSBN) ______________
• Approval Status/Student Number is considered a licensure and can be verified at http://www.lsbn.state.la.us
under the Licensure tab using Name and Social Security.
Reason for resubmission (check all that apply):
_______ Changing School of Nursing
_______ Readmission after academic failure
_______ Previously delayed- providing new information
_______ Other - Please Explain: _________________________________________
SECTION II. TO BE COMPLETED BY THE APPLICANT
For all questions in this section:
• You must attach all requested documents listed for questions with “YES” answers. Applications will
not be processed until the items are received. Do not write responses directly on this application.
Please initial and date any errors made on this application.
• If you pr
eviously applied and checked “YES”/Disclosed and provided ALL of the listed documents
for the applicable question, then:
Check “yes” for appropriate question
Provide signed narrative as outlined under question and include statement regarding previous
disclosure and submission of information to LSBN.
If there is no new information/ please include statement stating this.
Yes__No__ 1. Have you ever been issued:
a citation or summons for,
has/have warrant(s) been issued against you related to,
have you been arrested, charged with, arraigned, indicted, convicted of,
pled guilty/”no contest”/nolo contendere/“best interest” or any similar
been sentenced for any criminal offense, in Louisiana or other
NOTE: Even though an arrest or conviction has been, dismissed, deferred, or diverted,
and even if your civil rights have been restored, you must answer “YES” and mail
certified court documents of incident/arrest together with a signed letter of
NOTE: No person whose record of arrest or conviction has been expunged [ordered
sealed, non-disclosed, and/or pardoned by a court in the applicant’s state or
jurisdiction] shall be required to disclose to any person that he [or she] was arrested or
convicted of the subject offense, or that the record of the arrest or conviction has
been expunged. La. C. Cr. P. Art. 973 (C). If the applicant does not know the
meaning of the terms set forth above, and/or has a question about the meaning of the
terms, then it is incumbent upon the applicant to seek legal counsel.
DWI arrest must be reported, regardless of final disposition.
Traffic violations such as speeding or parking tickets do not need
to be reported.