The New York Nurse 1 form is an essential application for individuals seeking licensure as a nurse in New York State. This form must be completed and submitted along with the appropriate fee to the Office of the Professions. Proper completion is crucial, as any omissions can delay the review process.
The New York Nurse 1 form serves as a critical step for individuals seeking licensure as either a Registered Professional Nurse or a Licensed Practical Nurse in the state of New York. This application is not merely a formality; it requires careful attention to detail and thorough completion. Applicants must provide personal information, including their Social Security number, date of birth, and contact details, ensuring accuracy across all documents. The form necessitates a fee of $143, which encompasses both the application and initial registration costs. Importantly, applicants must ensure that their name matches exactly on the application, photo identification, and NCLEX application to avoid potential delays in testing authorization. The form also includes a series of questions regarding past legal issues and professional conduct, requiring full transparency. Additionally, applicants must disclose their educational history, including details about nursing programs attended, and confirm compliance with child support obligations and citizenship status. Notably, certain sections require notarization, emphasizing the seriousness of the information being provided. Completing the New York Nurse 1 form accurately is essential, as any omissions or errors can lead to significant delays in the licensure process.
This form is mandatory for all applicants seeking licensure as a nurse in New York. Submitting the form is a crucial step in the application process.
The application fee of $143 is non-refundable. This fee covers both the application and the first registration period.
It is essential to sign and date the affidavit in the presence of a Notary Public. Without this step, the application will not be valid.
The name on the application must match exactly with your photo ID and NCLEX application. Any discrepancies can delay your testing authorization.
All questions must be answered completely. Leaving any required parts blank can result in delays in processing your application.
All applicants must disclose any past criminal charges or disciplinary actions. Failing to do so can lead to serious consequences for your application.
The identification used must be a photo ID that matches the name on the application. This is crucial for verifying your identity during the licensure process.
When filling out the New York Nurse 1 form, it’s essential to follow specific guidelines to ensure a smooth application process. Here are six crucial dos and don’ts:
By adhering to these guidelines, you can help ensure that your application is processed efficiently and without unnecessary delays.
The University of the State of New York
This Area For Department Use Only
The State Education Department
Nurse Form 1
Office of the Professions
Application for Licensure
Division of Professional Licensing Services
www.op.nysed.gov
All applicants for licensure must complete this form and submit it with the appropriate fee ($143) directly to
the Office of the Professions at the address at the end of this form. The $143 fee is the total of the application
fee ($70) plus the fee for your first registration period ($73). The application portion of the fee is not refundable.
You must answer all questions in ink (pen or printer) and provide all information requested unless otherwise
indicated. Failure to complete all required parts of the application will delay its review. You must sign and date
the Affidavit on this form in the presence of a Notary Public.
Check what you are applying for (check one):
Registered Professional Nurse
22
$143
ER
Licensed Practical Nurse
10
The name listed on your application for licensure, the name on your photo identification, and the name listed on your NCLEX application must ALL match EXACTLY. If your name does not exactly match in all instances it will delay your authorization to test (ATT), you may not be allowed to take the exam at your scheduled time and you may incur additional fees to test.
1.
Social Security Number
2. Birth Date
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3.
Print Name
Last
First
5.
Telephone/Email Address
Daytime Phone
Middle
Home or
Business
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
4.
Mailing Address
Area Code
Phone
(You must notify the Department promptly of any address or name changes)
Email Address (please print clearly)
Line 1
Line 2
Line 3
6. New York State DMV ID Number
City
(Driver or Non-Driver ID)
State
ZIP Code
(Leave this blank if you do not have a
Country/
New York State DMV ID Number)
Province
7.
Do you have a CGFNS record?
Yes
No
If "yes", enter your CGFNS Number:
8.
Name as it appears on degree or other credentials (if different from above)
9.
Have you ever applied for New York State licensure in any profession?
If "yes", in what profession(s)?
10.
Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime
(felony or misdemeanor) in any court?
11.
Are criminal charges pending against you in any court?
12.
Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled,
accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate
held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you?
13.
Are charges pending against you in any jurisdiction for any sort of professional misconduct?
14.
Has any hospital, licensed facility or clinical laboratory restricted or terminated your professional training,
employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association
to avoid imposition of such measures?
NOTE: If you answer "Yes" to any questions numbered 10-14, submit a letter giving a complete detailed explanation. Include copies of any court records including a Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. In answering these questions, consider whether, pursuant to Executive Law § 296(16), you are required to report any arrests, criminal accusations, or dispositions of such arrests or criminal accusations. If the court can no longer provide documentation, you must request, from the court, a letter stating why they cannot provide the documents. While your application is pending, you must notify the Division of Professional Licensing Services if the answers to any of these questions have changed.
Nurse Form 1, Page 1 of 4, Revised 11/19
15. Do you now hold, or have you ever held, a license or certificate to practice any profession in any state or jurisdiction?
If yes, list each license/certificate, state or jurisdiction and provide appropriate information in the columns below. A Form 3 or Nursys
license verification (for states reporting to Nursys) must be submitted for each professional license/certificate listed unless it is a license/certificate issued by the New York State Education Department. See the Applicant instructions on Form 3 for specific information about completing and submitting the form.
Professional Title
State or Jurisdiction
Date License/Certificate
License/Certificate
Issued
Number
Limitations
on License/Certificate
16.You must complete all information for all schools/colleges/universities attended or your application will be considered incomplete. Note: If you are applying for licensure as a licensed practical nurse and you did not graduate from a New York State approved nursing program, you must submit a copy of your high school or secondary school diploma or transcript in the original language with your Form 1. If you were educated outside the U.S. or a Canadian province other than Quebec with a BN, BSN or BScN after
January 1, 2015), submit a copy of your nursing diploma in the original language.
Elementary or Primary School - Please complete the section below with details about your elementary or primary school. Attach additional sheets if you attended multiple schools. Any missing information will be considered an incomplete application.
Name of School
State/Province
Country
Number of years attended
Attendance from
to
Completion date
mo.
yr.
High School/Secondary School or Equivalency Diploma Issuer - Please complete the section below with details about your high school/secondary school or equivalency diploma issuer. Attach additional sheets if you attended multiple schools. Any missing information will be considered an incomplete application.
Nurse Program - Please complete the section below with details about your nursing program. Attach additional sheets if you attended multiple programs. Any missing information will be considered an incomplete application.
Major/Concentration
Title of Degree/Diploma/Certificate awarded (in original language)
Or
Still in progress
Date Degree/Diploma/Certificate awarded
Postsecondary Education - Please complete the section below with details about your postsecondary education. Attach additional sheets if you attended multiple schools. Any missing information will be considered an incomplete application.
Nurse Form 1, Page 2 of 4, Revised 11/19
17.If you have ever taken the SBTP, NCLEX, or a state-constructed examination for licensure as either a Registered Professional Nurse or a Licensed Practical Nurse in the United States or its territories (except New York State), complete the following:
State or Territory*
Profession
Exam Name
Exam Date
If Granted, License No.
*If you took the NCLEX or SBTP Examination, send Form 3 to the state in which you passed the licensing examination or request verification from Nursys.
18.Child Support Obligation
Everyone applying for a professional license, permit, or registration, or any renewal thereof, must certify that, as of the date of the filing, she or he is, or is not, under an obligation to pay child support*. Individuals who are four months or more in arrears in child support or who have failed to comply with a summons, subpoena or warrant relating to a paternity or child support proceeding may be subject to suspension of their business, professional, drivers and/or recreational licenses and permits. The intentional submission of false written statements for the purpose of frustrating or defeating the lawful enforcement of support obligations is punishable under section 175.35 of the Penal Law.
You must complete this section before we can issue the credential for which you have applied. Individuals who are not in compliance with their obligation to pay child support can be issued a credential for no more than six months in order to comply with their child support obligations.
CHECK ONLY A OR B BELOW. If you check B, you must check one of the five statements listed below it.
A I am not under an obligation to pay child support;
B I am under an obligation to pay child support and (please check only one of the following)
I am current and am not four months or more in arrears in the payment of child support; or,
I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties; or,
The child support obligation is the subject of a pending court proceeding; or,
I am receiving public assistance or supplemental security income; or, None of the above four statements apply.
*New York State General Obligations Law, section 3-503
19.Citizenship/Immigration Status
Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses, registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner’s regulation, you must complete this section of this form and check the appropriate box below which indicates your citizenship/immigration status.
I am:
A. A United States citizen or National.
B. An alien lawfully admitted for permanent residence in the United States.
C. An alien granted asylum under Section 208 of the Immigration and Nationality Act.
D. A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
E. An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1 year.
F. An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
G. An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April 1980.
H. Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach a copy of your passport if you are not required to have a Visa to enter the United States
I. I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or similar relief from deportation. Please specify
J. I do not reside in the United States.
If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship and Immigration Services (USCIS): USCIS number
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL LAW SHOULD BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283,
OR VISIT THE USCIS WEBSITE.
Nurse Form 1, Page 3 of 4, Revised 11/19
20. Child Abuse Identification and Reporting Coursework Requirement - RN Applicants Only (check one)
I graduated from a NYS registered program and completed the child abuse identification training as part of my studies.
I completed the child abuse coursework and have enclosed a certificate of completion from an approved provider
I completed the child abuse coursework online and the approved provider will report that to you electronically. I am filing for an exemption to the requirement and have enclosed the Certification of Exemption (Form 1CE).
21. Infection Control Training Requirement (check one)
I graduated from a NYS registered licensure qualifying program within the last four years and completed the infection control training during my studies.
I completed the infection control training within the last four years and have enclosed a certificate of completion from an approved provider.
I completed the infection control training online within the last four years and the approved provider will report that to you electronically.
I am filing for an exemption to the requirement and have enclosed an Attestation of Infection Control Training (Form 1IC).
22. Reasonable Testing Accommodations for Individuals with Disabilities. (check if applicable)
I have been diagnosed as having a disability and require special testing accommodations and am submitting the Request for Reasonable Testing Accommodations form. I understand that I will not be able to test until I submit the appropriate documentation and am approved to test with accommodations. (Visit the Office of the Professions' website for information on obtaining the form.)
23.Gender and Ethnicity (This item is optional)
Information on gender and ethnicity is sought solely to allow the New York State Education Department to collect and analyze data concerning diversity in the licensed professions. The ethnic and gender data you provide will be used only for statistical, research, and program evaluation purposes. It will not be released to the public. This information has absolutely no bearing on your qualification for
licensure.
Gender
Male
Female
Ethnicity
White (not Hispanic)
Black (not Hispanic)
Asian
Hispanic
Native American
24. Education Program Review
I give permission to the New York State Education Department to release my examination results to my professional school for the confidential purposes of program review and institution research and planning. I may rescind this authority at any time by notifying the
Division of Professional Licensing Services in writing.
Please initial
25.Affidavit with Acknowledgement (Notarization required)
Applicant
I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I understand that any false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure and may result in criminal prosecution. This form must be signed and dated in the presence of a Notary Public.
Applicant's Signature
Date
Notary
State of
County of
On the
day of
in the year
before me, the above signed,
personally appeared
, personally known to me or proved to me on the basis
Applicant name
of satisfactory evidence to be the individual whose name is subscribed to this application and acknowledged to me that he/she executed
the application and swore that the statements made by him/her in the application and all supporting materials are true, complete, and
correct.
Notary Public's Signature
Notary Stamp
Notary ID number
Expiration Date
If you are submitting an initial Form 1, mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201, U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
If the Department has requested an updated Form 1, mail this form to: New York State Education Department, Office of the Professions, Nurse Unit, 89 Washington Avenue, Albany, NY 12234-1000. NO FEE IS NEEDED FOR THIS OPTION.
Nurse Form 1, Page 4 of 4, Revised 11/19
The New York Nurse 1 form is an application for licensure that individuals must complete to become a Registered Professional Nurse or a Licensed Practical Nurse in New York State. This form must be submitted along with a fee of $143, which covers both the application fee and the first registration period. It's crucial to fill out this form accurately and completely to avoid delays in processing your application.
When filling out the New York Nurse 1 form, you will need to provide various personal details, including:
Make sure to answer all questions in ink and provide the requested information to prevent your application from being considered incomplete.
It is essential that the name you provide on the application matches exactly with your photo ID and NCLEX application. If there are discrepancies, it could lead to delays in your authorization to test (ATT). In some cases, you might even be unable to take the exam as scheduled, which could incur additional fees. Always double-check that your name is consistent across all documents before submission.
If you have ever been found guilty of a crime or have pending charges, you must disclose this information on the application. Questions numbered 10-14 on the form specifically address criminal history and professional misconduct. If you answer "Yes" to any of these questions, you are required to provide a detailed explanation and include any relevant court records. Transparency is crucial, as failing to disclose this information could jeopardize your application.
Once you have completed the New York Nurse 1 form and included the appropriate fee, you must mail it to the New York State Education Department, Office of the Professions. For initial applications, send it to:
New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201, U.S.A.
Do not send cash; instead, make your check or money order payable to the New York State Education Department. If you are submitting an updated form as requested by the Department, send it to:
New York State Education Department, Office of the Professions, Nurse Unit, 89 Washington Avenue, Albany, NY 12234-1000.
No fee is required for this option.
Completing the New York Nurse 1 form is a critical step in the licensure process for nursing professionals. This form must be filled out accurately and submitted with the required fee to ensure timely processing of your application. Below are the steps to guide you through the completion of the form.
When filling out the New York Nurse 1 form, many applicants inadvertently make mistakes that can lead to delays in their licensure process. One common error is failing to ensure that their name matches exactly across all documents. The name on the application, photo ID, and NCLEX application must be identical. Any discrepancies can result in a delay in authorization to test, which can be frustrating and costly.
Another frequent mistake is neglecting to complete all sections of the form. Each question is designed to gather essential information, and leaving any part unanswered can render the application incomplete. This oversight can lead to significant delays as the application will not be processed until all required information is provided.
Applicants often overlook the requirement to sign and date the affidavit in the presence of a Notary Public. This step is crucial; without proper notarization, the application may be deemed invalid. It is important to remember that this is not merely a formality but a legal requirement that must be adhered to strictly.
In addition, many individuals fail to provide a valid Social Security Number. If an applicant does not have one, they should leave that section blank, as instructed. However, if a Social Security Number is provided, it must be accurate. Any errors in this number can lead to complications in processing the application.
Another area where applicants stumble is in the child support obligation section. It is vital to accurately report one’s status regarding child support. Misrepresenting this information can have serious consequences, including the potential suspension of various licenses.
Moreover, applicants sometimes forget to include required documentation when answering questions about previous licenses or criminal history. If an applicant answers "yes" to any of the questions regarding past convictions or disciplinary actions, they must provide detailed explanations and supporting documents. Failing to do so can result in a denial of the application.
Many people also make the mistake of not notifying the Department promptly about any changes in their address or name after submitting the application. Keeping the Department informed is essential for smooth communication and processing of the application.
Additionally, some applicants neglect to check the appropriate boxes regarding their citizenship or immigration status. This information is crucial for compliance with federal law and must be completed accurately to avoid delays.
Lastly, a common error is providing incomplete educational history. Applicants must list all schools attended, including elementary, secondary, and nursing programs, along with the corresponding dates and details. Missing information will be considered an incomplete application and can lead to further delays.
By being mindful of these common mistakes, applicants can enhance their chances of a smooth and timely licensure process. Taking the time to carefully review the form and ensuring all information is accurate and complete can save applicants from unnecessary headaches down the line.
Ensure you complete the New York Nurse 1 form accurately. All questions must be answered in ink, and any missing information can delay the review process.
Pay attention to the fee structure. The total fee is $143, which includes a $70 application fee and a $73 registration fee. Remember, the application fee is non-refundable.
Your name must match exactly across all documents. This includes your application, photo ID, and NCLEX application. Discrepancies can lead to delays or additional testing fees.
Be aware of the importance of notarization. You must sign the affidavit in front of a Notary Public. This step is crucial for the validity of your application.
If you answer "yes" to any questions regarding criminal history or professional misconduct, you must provide detailed explanations and relevant documentation. This can significantly impact your application.
Bill of Sale Car - Essential for ensuring that all necessary information is communicated clearly between the seller and buyer.
It-203 - Queries about any rights to acquire significant stock interests in the coming years highlight the city's interest in future changes in vendor ownership and influence.
Where Can I Get Tax Forms Near Me - The form acts as a comprehensive summary, necessitating thoroughness to include all taxable income and withholdings.