West Virginia Board of Examiners
for Registered Professional Nurses

101 Dee Drive Suite 102
Charleston, WV 25311-1620
Phone: (304) 558-3596 or 1-877-743-NURS(6877)
Fax: (304) 558-3666
Web Address: www.wvrnboard.com Email: rnboard@wv.gov
ALL LICENSES EXPIRE ANNUALLY OCTOBER 31ST
  
Endorsement Application and Instructions:
Application Fee: $100.00  Temporary Permit: Additional $25.00  For both: $125.00 by money order or cashiers check
(printable)
 
A verification of license from your original state of licensure is required before a permanent license can be issued.  Send the verification request to the appropriate place immediately to avoid delays in processing your license.
 
 
INSTRUCTIONS FOR APPLICATION BY ENDORSEMENT
 
 If the applicant has ever been licensed to practice Registered Professional Nursing in West Virginia, please request the REINSTATEMENT FORM. You may call the Board office at
304-558-3596 for the correct form or download it from the web site listed above.
 
ALL OTHER APPLICANTS MUST COMPLETE THE ENDORSEMENT FORM AS FOLLOWS: 

1. Complete the  APPLICATION FOR LICENSURE BY ENDORSEMENT and sign the affidavit before a notary public with a seal.

2.  Attach a color, two inch by two inch (2" x 2") passport photo of yourself with YOUR SIGNATURE ACROSS THE FRONT ALONG THE BOTTOM OF THE PICTURE, ON THE PICTURE. (See page 3.) *No nursing caps, please. It is important to send an identification photo. The application will be returned if the photo does not meet the requirements. No glamour shots, side photos, photos with other persons or structures in them.

3. Return the completed notarized APPLICATION FOR LICENSURE BY ENDORSEMENT form, with the signed passport photograph. Submit a one hundred (100) dollar fee by MONEY ORDER or CERTIFIED CHECK made payable to: WEST VIRGINIA BOARD OF RNs.

4. Complete the top part of the WV Verification Form and mail it to the Board office in the STATE WHERE YOU WERE ORIGINALLY LICENSED. It is recommended that you call your original state of licensure prior to mailing this form to obtain information on any fees required for this service. 

WV Verification Form is the form to use when your original state of licensure is NOT part of the Interstate Compact.  Send verification form to your original state of licensure immediately to assure it is processed before the Temporary Permit expires.
 
 
OR 
5. If you are from a state which observes Mutual Recognition go to https://www.nursys.com/ their fee is $30 by credit card.
 
6. To Apply For a Temporary Permit: Complete the Temporary Permit application on page five (5) of the application. Temporary Permit fee is an additional twenty-five dollars ($25.00). The total fee for endorsement and a Temporary Permit is one hundred and twenty five dollars ( $125.00) by money order or cashiers check.
 
THE WEST VIRGINIA CODE PROHIBITS YOUR EMPLOYMENT IN REGISTERED PROFESSIONAL NURSING IN WEST VIRGINIA UNTIL YOU RECEIVE A CURRENT LICENSE OR A VALID CURRENT TEMPORARY PERMIT ISSUED BY THE WEST VIRGINIA BOARD OF EXAMINERS FOR REGISTERED PROFESSIONAL NURSES.
Once all necessary information is received by this office, the application is reviewed. If you meet West Virginia qualifications for licensure as a registered professional nurse, a license to practice as such will be issued. 
 
FEES DEPOSITED FOR LICENSURE BY ENDORSEMENT ARE NOT REFUNDABLE.

** For Advanced Practice Recognition, a separate application must be requested.

*** After six (6) months, applications not verified are considered abandoned; a new application must be submitted

(EI 5/2006) All licenses expire October 31st of each year regardless of issue date

 mark your application "hold til October" at top right corner if you want your license after 10/01/2013
 
ENDORSEMENT APPLICATION
 
 

1. Name: (First) spacer gif    (Middle) spacer gifspacer gif      (Last) spacer gif
2. Other Names:
List any other legal names you have had.
 
 
(Maiden) spacer gif
3. Soc. Sec. Number: spacer gif
4. Address:
Street or PO box number
City State ZIP
spacer gif
5. Date of Birth: Date: spacer gif/ spacer gif/ spacer gif
spacer gifmm/dd/yyyy
6. Place of Birth: City spacer gifState spacer gif
7. U. S. Citizen: (Circle One) spacer gifYes spacer gifNo
8. Gender: (Circle One) spacer gifMale spacer gifFemale
9. Marital Status: (Circle One) spacer gifSingle spacer gifMarried spacer gifDivorced spacer gifWidowed spacer gif
10. Race/Ethnic origin: (Circle One) spacer gifa. Caucasian (white) spacer gifb. African American (black) spacer gifc. American Indian or Alaskan Native spacer gifd. Asian or Pacific Islander spacer gife. Hispanic spacer giff. Other (list) spacer gif
11. Phone numbers:
Provide numbers where you may be reached during the day.
spacer gif
12. High School: Name of High School: spacer gifCity spacer gifState spacer gif
13. Date of graduation:

If you did not graduate from high school, provide General Education Development (G.E.D.) Info.

Date: spacer gif/ spacer gif/ spacer gif
spacer gifmm/dd/yyyy
14. Date of G.E.D. Date: spacer gif/ spacer gif/ spacer gif
spacer gifmm/dd/yyyy
15. SCORE: spacer gif
Basic Nursing Education Program Information spacer gif
16. Name of Program: Name spacer gifCity spacer gifState spacer gif
17. Degree type: (Circle One) spacer gifHospital Diploma       Associate spacer gifBaccalaureate
18. Date of graduation: Date: spacer gif/ spacer gif/ spacer gif
spacer gifmm/dd/yyyy
19. Additional education (Degree Held): Yes spacer gifNo spacer gifAssociate Degree
Yes spacer gifNo spacer gifB. S. Nursing
Yes spacer gifNo spacer gifB.S. or B.A. (Non-Nursing)
Yes spacer gifNo spacer gifMasters in Nursing
Yes spacer gifNo spacer gifMasters (Non-Nursing)
Yes spacer gifNo spacer gifDoctoral Degree (Nursing)
Yes spacer gifNo spacer gifDoctoral Degree (Other Field) Degree: spacer gifField:
20. Do you have advanced practice certification? (Circle one) spacer gifYes spacer gifNo
21. If yes, and you desire Announcement of Advanced Practice by the Board, please contact this office for an application or print out or download this form.
22. State of Original Licensure: (Request verification from this state) State:        License Number:             Issue date:          Expiration Date: spacer gif
23. List ALL other states where you are or have ever been licensed. State License Number Date Issued Date Expired
General Application Questions spacer gif
Do you hold or have held ANY OTHER professional or occupational licensure or certification?

(Circle one) spacer gifYes spacer gifNo spacer gifIf yes please provide the following information:
Type of license or certification _______________________________ State: ________________
License/certification number _______________________________ Expire date: ________________
phone number for verification _______________________________
Do you have a child support obligation?

(Circle one) spacer gifYes spacer gifNo spacer gif
Do you have an arrearage that equals or exceeds the amount of child support payable for six (6) months?

(Circle one) spacer gifYes spacer gifNo
Are you the subject of a child support subpoena or warrant?

(Circle one) spacer gifYes spacer gifNo
Do you own all or part of a business that operates within West Virginia?

(Circle one) spacer gifYes spacer gifNo spacer gifIf YES, list the FEIN# __________________
WV Code 21A-2-6(18) provides that a board may not issue or renew a license for you to engage in the practice of a profession if you are in default under either the unemployment compensation laws or the worker's compensation laws, or under both laws of this State.
 
Have you ever or are you currently serving in a branch of the military?(Circle One) YES NO
If so which branch ____________________________
A. Have you ever been discharged from a branch of the military with anything other than an honorable discharge?
(Circle One) YES NO        If yes send explanation and DD214
 
***If answering YES to ANY of the questions below*** attach an explanation and certified copies of related court documents and State Board Action if applicable. Traffic violations resulting in convictions must be reported. If you have questions, please contact the Board office at (304) 558 - 3596 to speak with someone in the Discipline Department.
Have you EVER been convicted of a felony or a misdemeanor or pled nolo contendere to any crime.  Minor traffic violations such as speeding or parking tickets do not have to be reported.

(Circle one) spacer gifYes spacer gifNo spacer gifIf yes, attach explanation and certified copies of court documents.
Has your license ever been denied, revoked, suspended, surrendered or otherwise disciplined in any state?

(Circle one) spacer gifYes spacer gifNo spacer gifIf YES, attach an explanation and have certified copies of related documents mailed directly from the Board of Nursing taking the action.
Have you ever or are you currently abusing prescription or over-the-counter medication?

(Circle one) spacer gifYes spacer gifNo
Have you ever or are you currently using illegal drugs?

(Circle one) spacer gifYes spacer gifNo
Is there any reason why your access to narcotics or substances of abuse should be restricted or limited?

(Circle one) spacer gifYes spacer gifNo
Do you currently posses any condition which may in any way impair your ability to practice or otherwise alter your behavior as it relates to the practice of registered professional nursing?

(Circle one) spacer gifYes spacer gifNo
Has your nursing practice ever been disciplined or monitored for any reason, including monetary fines, continuing education, etc., by any facility, board or group?

(Circle one) spacer gifYes spacer gifNo
 
Has a complaint ever been filed against your nursing practice in any other state or jurisdiction?
 
(Circle one) spacer gifYes spacer gifNo
Provide information on CURRENT or MOST RECENT employment:

Name of Employer:
Location:
City
County
State
ZIP
Attach a color 2" x 2" IDENTIFICATION PHOTO in the space provided. This photo is for identification purposes and should look as much as possible like you usually look.
Sign your name ON THE front of the PICTURE before attaching to application. DO NOT mark across the face.  Signing on the picture allows it to be identified if it is separated from the application. 
 
Do not send snap shots or copy of drivers license.
 
Place signature on the front of the picture.
spacer gif

 

AFFIDAVIT

STATE OF _________________________

COUNTY OF ________________________

I, the undersigned, being duly sworn, according to law, do depose and say that I am the person whose photograph is attached hereto and who is referred to in the foregoing application; that the information supplied therein is true to the best of my knowledge; and that I have read and understand this affidavit. I understand that supplying false information on this application is ground for denial of licensure or disciplinary action against the license. FURTHER: I authorize the release of all documents compiled by any law enforcement agency pertaining to me to the Board upon the request of the Board or its agent. Said release includes records in existence as of this date, as well as those compiled at any time in the future.


Applicant Signature ________________________________

Subscribed and sworn to before me this ________________ day of __________________ , 20___.

My commission expires on the ________________ day of __________________ , 20___.

(SEAL)

 

Notary Signature ________________________________

Notary Public in and for

 

COUNTY ________________________

STATE _________________________



Send money order or certified check (NO PERSONAL CHECKS)

MONEY NOT REFUNDABLE - APPLICATION AND FEE GOOD FOR SIX (6) MONTHS

TO OBTAIN A TEMPORARY PERMIT COMPLETE THE TEMPORARY PERMIT APPLICATION BELOW ALONG WITH THE APPLICATION FOR ENDORSEMENT: ___________________________________________________________________________



Temporary Permit Application:
(printable)

COMPLETE ONLY IF YOU WISH TO OBTAIN A 180-DAY TEMPORARY PERMIT TO PRACTICE.

THE TOTAL OF $125.00 IS REQUIRED FOR ENDORSEMENT AND A TEMPORARY PERMIT.

 TYPE OR PRINT LEGIBLY.
Name of Agency where you plan to seek employment in West Virginia:
Agency Name
Address
Phone

If you are employed by a nurse placement service or "traveling nurses agency" give name of agency, address, and phone number below.
Agency Name
Address
Phone


AFFIDAVIT

This is to certify that I have a current, valid license to practice nursing as a Registered Nurse in another state as follows:

State of Current Licensure __________________

License Number (in another state) __________________

Expiration Date of current license __________________

I further certify that my license is in good standing; I have had no disciplinary action taken on my license and no disciplinary action is pending. I further certify that I passed the NCLEX-RN or SBTPE examination given in the United States of America.

I further certify that I am responsible for knowing and practicing according to the West Virginia laws and rules governing the practice of registered professional nurses.

Applicant Signature ________________________________
Date ________________



Sworn to and signed before me this ________________ day of __________________ , 20___.

My commission expires on the ________________ day of __________________ , 20___.

Notary Seal or Stamp

 

Signature of Notary Public ________________________________

Expiration Date of Commission ________________________
 
 
 
WV Verification Form is the form to use when your original state of licensure is NOT part of the Interstate Compact.  Send verification form to your original state of licensure immediately to assure it is processed before the Temporary Permit expires.
 
 NURSYS Verification  use when your original state of licensure IS part of the Interstate Compact.   
 
 
E/I rev. 09/2013
 
 

 


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