Wisconsin Department of Safety and Professional Services
APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:
Application (Form #3210)
Convictions and Pending Charges (Form #2254), if applicable
Malpractice Suits or Claims (Form #2829) and copies of
malpractice suit, court documents with allegations and
settlement, if applicable.
Is name on all credentials the same? If not, submit certified copy
of marriage certificate, divorce decree, etc.
Fingerprints via FieldPrint
Authorization for Release of FBI Information (Form #2687),
with photograph (head and shoulders only).
I AM OR HAVE BEEN LICENSED IN THE FOLLOWING STATE(S). (Include all active and inactive states.)
ANSWER THE FOLLOWING QUESTIONS. (Attach additional sheets if necessary.)
1. Have you ever surrendered, resigned, canceled, or been denied a professional license or other credential in Wisconsin, or any
other jurisdiction? If yes, give details on an attached sheet, including the name of the profession and the agency.
Yes No
2. Have you ever failed to pass any state board examination, province of Canada examination, or NCLEX? If yes, give details. Yes No
3. Has any licensing or other credentialing agency ever taken any disciplinary action against you, including but not limited to
any warning, reprimand, suspension, probation, limitation, or revocation? If yes, attach a sheet providing details about the
action, including the name of the credentialing agency and date of action.
Yes No
4. Have you ever been terminated from any employment related to nursing that occurred within the 10 years immediately
preceding the date of this application?
If yes, give related details in a personal statement, including name of employer(s)
and date(s) of employment and facts involved in being terminated. Attach any additional documentation regarding
termination, including but not limited to any written warning or termination letter. If no documentation is available,
please attest to that in your personal statement.
Yes No
5. Is disciplinary action pending against you in any jurisdiction? If yes, attach a sheet providing details about pending
action, including the name of the agency and status of action.
Yes No
6. Since the date your Wisconsin single-state licensure was granted or last renewed (whichever occurred most recently), have
you been convicted of a misdemeanor, felony, or other violation of federal, state, or local law or do you have any felony,
misdemeanor, or other violation of federal, state, or local law charges pending against you in this state or any other? This
includes municipal ordinances resulting only in monetary fines or forfeitures and convictions resulting from a plea of no
contest, a guilty plea.
If yes, submit Convictions and Pending Charges Form #2254 and supporting documentation for each conviction and
pending charge since the date your license was granted or last renewed (whichever occurred most recently).
If no, submit Convictions and Pending Charges Form #2254 without previously submitted documentation.
Yes No
7. Are you incarcerated, on probation, or on parole for any conviction? If applicable, attach a sheet providing details
including the terms of incarceration and a copy of a report from your probation or parole officer.
Yes No
8. Have any suits or claims ever been filed against you as a result of professional services? If yes, submit a copy of the claim
or suit and a copy of the final settlement or disposition and complete Malpractice Suits or Claims (Form #2829).
Yes No
9. Are you registered, certified, or licensed in any other profession(s)? If yes, state what profession(s) and in what state(s): Yes No
10. Have you ever been credentialed under any other name(s)? If yes, state name(s) credentialed under: Yes No
For the purposes of these questions, the following phrases or words have the following meanings:
"Ability to practice as a Registered Nurse/Licensed Practical Nurse " is to be construed to include all of the following:
1. The cognitive capacity to make appropriate clinical diagnoses and exercise reasoned nursing judgments and to learn and keep abreast of nursing
developments; and
2. The ability to communicate those judgments and nursing information to patients and other health care providers, with or without the use of aids or
devices, such as voice amplifiers; and
3. The physical capability to perform nursing tasks such as physical examination and surgical procedures, with or without the use of aids or devices,
such as corrective lenses or hearing aids.
"Medical Condition" includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic, visual, speech, and
hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, intellectual disability, emotional
or mental illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction and alcoholism.
#3210 (Rev. 12/31/2021)
Wis. Stat. ch. 441
Committed to Equal Opportunity in Employment and Licensing Page 2 of 3
