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New Jersey Ofce of the Attorney General INFORMATION (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
www.njconsumeraffairs.gov/medical/nursing.htm
INFORMATION REGARDING NURSE LICENSURE BY EXAMINATION
FOR GRADUATES OF FOREIGN NURSING PROGRAMS
_____________________________________________
Enclosed is an Application Packet for Licensure by Examination for Graduates of Foreign Nursing
Programs. Read all of the directions carefully and make sure that you have checked the type of
nursing license for which you wish to apply. Mail the completed application with a fee of $225.00
($120.00 license fee, $100.00 application fee and a $5.00 surcharge fee) and the Certication and
Authorization Form for a Criminal History Background Check to the New Jersey Board of Nursing
at the above mailing address.
There are ve (5) elements required for licensure of a foreign graduate as a nurse in New
Jersey including:
1. A transcript review by the Commission on Graduates of Foreign Nursing Schools (C.G.F.N.S.).
Please request the Full Education Course by Course Report.
2. Proof that you have achieved a passing score on the Test of English as a Foreign Language
exam, TOEFL (C.G.F.N.S. is also providing English language evaluations) (Must be submitted
only to C.G.F.N.S.);
3. A completed licensure application for graduates of foreign nursing programs, which includes
information concerning your educational and experiential background;
4. Criminal History Background Check clearance.
5. Successful completion of the appropriate NCLEX licensing examination.
Please submit the following to the New Jersey Board of Nursing:
• The ofcial Application for Licensure by Examination for Foreign Graduates;
• One original color (2” x 2”) passport-style photograph;
• Copy of your Social Security card;
• Copy of your birth certicate or other immigration documents;
• The total fee of $225.00, payable to the New Jersey Board of Nursing, (a money order or
personal check is acceptable); and
• The Certication and Authorization Form for a Criminal History Background Check.
NCLEX (National Council of State Boards of Nursing Examinations)
To register for the NCLEX examination, please visit the Candidate Web Site at www.pearsonvue.
com/nclex or call Pearson Vue at 1-866-496-2539.
Criminal History Background Check
After the Board receives the completed Certication and Authorization Form for a Criminal History
Background Check, you will then receive instructions on the ngerprinting process. You will be
eligible to sit for the appropriate NCLEX licensing examination. However, you will not be permitted
to work or be licensed as a nurse in the State of New Jersey until the Criminal History Background
Check has been completed and the Board of Nursing has received the results. If the Criminal History
Background Check reveals a criminal conviction, a review of your application by the Board of
Nursing will be required.
For Further Information:
• Commission on Graduates of Foreign Nursing Schools (C.G.F.N.S.) at (215) 349-8767 or
www.cgfns.org
• The National Council of State Boards of Nursing’s NCLEX information & Candidate Bulletin
at www.ncsbn.org
You may email the following staff with questions regarding your application:
Diane Scott at diane.scott@lps.state.nj.us
Nilsa Taracena at nilsa.taracena@lps.state.nj.us
Or you may call the Board of Nursing at 973-504-6430.
RN/LPN Foreign Examination
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Ofcial Application for Nurse Licensure by Examination
For Graduates of Foreign Nursing Programs
Please check the license for which you are applying:
Registered Professional Nurse Licensed Practical Nurse
Are you re-testing?
Yes No
(If “Yes,” no fee is required by the New Jersey Board of Nursing.
However, you are required to re-register for NCLEX and pay Pearson/Vue.)
Date: _______________________________
Please enclose a nonrefundable examination application ling fee of $100.00, a license certicate fee of $120.00 and $5.00 surcharge fee
(for a total of $225.00) in the form of a check or money order made payable to the State of New Jersey. (Applicants should understand
that if the fees are paid with a personal check, and the check is returned by the bank due to insufcient funds, the next step in the licen-
sure or certication process will be delayed until the fees are paid.) The $100.00 fee covers the application only and the $5.00 surcharge
fee will not be refunded or held over.
The Board maintains, as part of its responsibilities, a record of your home address, business address and mailing address. You may choose
which of these addresses will be considered as your “address of record.” If you do not indicate (by putting a check in the appropriate box)
which address should be used as your address of record, your mailing address will be considered to be your address of record. A post of-
ce box may be used as your address of record, but only if you provide another address which includes a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _________________________
Month Day Year
Place of birth: ________________________
City State
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: ______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Business: ____________________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Reasonable Testing Accommodations for Individuals with Disabilities. (Check if applicable)
I have been diagnosed as having a disability and require special testing accommodations. I understand that I will not be able to
take the NCLEX until I submit the appropriate documentation and am approved to test with accommodations. (Appropriate
documentation includes ALL of the following: 1) a letter describing what type(s) of accommodations you are requesting (e.g.
double time, separate room, reader); 2) a letter from your current treating physician with a diagnosis code; and 3) a letter from
your nursing program describing the type(s) of accommodations you received during your nursing program.)
A t t ac h a cl ea r, fu l l - fa c e
color passport-style photograph
(2˝x 2˝) of your head and
shoulders, taken within the past
six months.
A photo is required with each
application.
Do not use staples to attach the
photo.
RN/LPN Foreign Examination
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*Social Security Number: __________ -____________ - ___________
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7,60.8 and 60.9, the Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
5. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of licensure or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
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signature
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RN/LPN Foreign Examination
6. Illegal Use of Controlled Dangerous Substances
The question below pertains to the illegal use of controlled dangerous substances. Please read the denitions carefully. Your responses
will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer this question if
you have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you
may assert the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in
good faith. If you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on
the application. Your application for licensure or certication will be processed if you claim the Fifth Amendment privilege against
self-incrimination. You should be aware, however, that you may later be directed by the Attorney General to answer a question that
you have refused to answer on the basis on the Fifth Amendment, provided that the Attorney General rst grants you immunity
afforded by statutory law, (N.J.S.A. 45:1-20).
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the previous
365 days, whichever is longer.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g. heroin
or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or not taken
in accordance with the directions of a licensed health care practitioner.
a. Are you currently engaged in the illegal use of controlled dangerous substances? (As stated above, “currently” is dened as
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
_____________________________________________________ ___________________________________
Applicant’s signature Date
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signature
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RN/LPN Foreign Examination
7. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
8. Do you currently hold, or have you ever held, a professional license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please provide that name. ____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
9. Have you ever been disciplined or denied a professional license or certicate of any kind in New Jersey, any other state, the District of
Columbia or in any other jurisdiction? Yes No
10. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
11. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any agency
or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
12. Have you ever been named as a defendant in any litigation related to the practice of nursing or other professional practice in New Jersey,
any other state, the District of Columbia or in any other jurisdiction?
Yes No
13. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.) Yes No
14. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
15. Are you aware of any investigation pending against a professional license or certicate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
16. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
17. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of nursing or other professional practice in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
If the answer to any of the above questions, numbers 9 through 17, is “Yes,” provide a complete explanation of the circumstances leading
to the action, and any supporting documentation, on separate sheets of paper.
RN/LPN Foreign Examination
Education
In the spaces below, give an accurate record of your educational preparation. Be sure to complete items A-D for each school. Use
additional sheets of paper if necessary.
A
B
C
D
A
B
C
D
A. Name of schools attended and locations
B. Number
of Years
Attended
C. Attendance
Entrance date
Leaving date
D. Title of diploma or degree
obtained*
High School or Primary School
________________________________________________
Name of school
_____________________________ ________________
City State/Country
________________________________________________
Name of school
_____________________________ ________________
City State/Country
Postsecondary School(s) including basic nursing
education programs
________________________________________________
Name of school Program major
_____________________________ ________________
City State/Country
________________________________________________
Name of school Program major
_____________________________ ________________
City State/Country
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
Check appropriate type:
Graduate diploma
Graduate equivalency
diploma
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
A. Name of schools attended and locations
B. Number
of Years
Attended
C. Attendance
Entrance date
Leaving date
D. Title of diploma or degree
obtained*
RN/LPN Foreign Examination
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: __________________________________________________
County of: ________________________________________________
I, ________________________________________________ , in making this application to the New Jersey Board of Nursing for
licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the New Jersey Board of
Nursing, swear (or afrm) that I am the applicant and that all information provided in connection with this application is true to the best
of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed sufcient
to deny licensure or certication or to withhold renewal of or suspend or revoke a license or certicate issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:11-23 et seq., together with the Rules and Regulations of the New Jersey Board
of Nursing, N.J.A.C. 13:37-1 et seq., and fully understand that in receiving licensure or certication from the Board, I bind myself to
be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
the purpose of verifying my qualications for licensure or certication. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records requested by
the Board.
__________________________________________________
Signature of applicant
Sworn and subscribed to before me this __________________
day of ____________________________ , ______________
Month Year
__________________________________________________
Name of Notary Public (please print)
Afx Seal Here
__________________________________________________
Signature of Notary Public
} ss.
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
CertifiCAtion And AuthorizAtion form
for A CriminAl history BACkground CheCk
Directions: Answer all of the questions on this form.
1. Name _________________________________________________________ ( ________________________)
Last First Middle Maiden Name
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
Month Day Year
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs
since November 2003? Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history background process.
Please send no payment now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certication by any other any other Board or Committee of the New Jersey Division of Consumer Affairs (a background
check conducted for the Department of Education, another state agency or another state does not apply) you will not be re-
quired to be ngerprinted a second time. However, the Division must perform a criminal history background check each time
you apply for licensure or certication. The fee for this service is $18.75. Payment should be made in the form of a check or
money order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor trafc offenses such as a parking or speeding
violations need not be listed.) Yes No
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within ve (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Mr.
Mrs.
Ms.
Board or Committee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
Dual License
License Type 1
________________________
Applicant’s Number
________________________
License Type 2
________________________
Applicant’s Number
________________________
RN/LPN Foreign Examination
RN/LPN Foreign Examination
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufcient to deny certication or licensure or to withhold renewal of or suspend or revoke a certicate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for
the purpose of verifying my qualications for certication or licensure. I further authorize all institutions, employers, agencies
and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________
_________________________________
Signature of applicant Date
Rev. 1/2/19
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New Jersey Ofce of the Attorney General INFORMATION (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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