For Office Use Only:
Texas Board of Nursing
Amount ___________________
333 Guadalupe, Ste. 3-460, Austin, TX 78701-3944
Phone: 512-305-7400 -- Web Site: www.bon.texas.gov
LVN
Date Recd__________________
License Renewal Form (Delinquent for over 90 days)
This renewal form is for Licensed Vocational Nurses renewing a license that expired over 90 day. Submit this form with the fee of $175.00 and 20 hours of
continuing education certificates. See the attached instruction for further details.
Name(Last):
(First):
LVN License Number:
(M):
Social Security Number:
-
-
Date of Birth:
/
Mo
(Address)
(City)
(State/Country)
(
(E-Mail Address)
/
Day
Yr
(Zip/Postal Code)
)
Business Fax Number
*For statistical information below, please use the statistical code sheet provided
*Employment Status: ______
*Primary Practice Setting: ______
*Primary Practice Position: ______
*Primary Specialty: ______
*Highest Degree: ______
*Primary Employment Zip: _________
In accordance with the Nursing Practice Act, section 304.001, art. 4 and 22 TAC §220.2, I declare that the State listed below is my
primary state of residence and that such constitutes my permanent and principal home for legal purposes. (“Primary state of
residence” is defined as the state of a person’s declared fixed permanent and principal home for legal purposes; domicile.)
Primary State of Residence:____________________________
Upon licensure in Texas, in which state(s) do you intend to practice?
[ ] No
[ ] Yes
Are you currently employed in the U.S. Military (Active Duty) or the U.S. Federal Government?
[ ] No
[ ] Yes
Have you used your nursing knowledge, skills and abilities within the past four (4) years?
Indicate the month and year that you last practiced as a Licensed Vocational Nurse:
Month ______________________ Year _______________
If you have been employed as a Licensed Vocational Nurse sometime within the past four years, please give the name and location
of your most recent employer:
Employer Name: __________________________________________________________________________________
Address: ________________________________________________________________________________________
City, State: ______________________________________________________________________________________
Licensee’s Name:
License Number:
Page 2 of 2
Eligibility Questions - Answering the questions below and signing the form is mandatory
1) [ ] No
[ ] Yes
*Have you, within the past 24 months or since your last renewal, for any criminal offense, including those
pending appeal:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
been convicted of a misdemeanor?
been convicted of a felony?
pled nolo contendere, no contest, or guilty?
received deferred adjudication?
been placed on community supervision or court-ordered probation, whether or not adjudicated
guilty?
been sentenced to serve jail or prison time? court-ordered confinement?
been granted pre-trial diversion?
been arrested or have any pending criminal charges?
been cited or charged with any violation of the law?
been subject of a court-martial; Article 15 violation; or received any form of military judgment/
punishment/action?
(You may only exclude Class C misdemeanor traffic violations or offenses previously disclosed to the Texas Board of
Nursing on an initial licensure or renewal application.)
NOTE: Expunged and Sealed Offenses: While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is
your responsibility to ensure the offense, arrest, ticket or citation has, in fact, been expunged or sealed. It is recommended that you
submit a copy of the Court Order expunging or sealing the record in question to our office with your application. Failure to reveal an
offense, arrest, ticket, or citation that is not in fact expunged or sealed, will at a minimum, subject your license to a disciplinary fine. Nondisclosure of relevant offenses raises questions related to truthfulness and character.
NOTE: Orders of Non-Disclosure: Pursuant to Tex. Gov’t Code § 552.142(b), if you have criminal matters that are the subject of an
order of non-disclosure you are not required to reveal those criminal matters on this form. However, a criminal matter that is the subject
of an order of non-disclosure may become a character and fitness issue. Pursuant to other sections of the Gov’t Code chapter 411, the
Texas Board of Nursing is entitled to access criminal history record information that is the subject of an order of non-disclosure. If the
Board discovers a criminal matter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the
Board may require you to provide information about any conduct that raises issues of character.
2) [ ] No
[ ] Yes
Are you currently the target or subject of a grand jury or governmental agency investigation?
3) [ ] No [ ] Yes
Has any licensing authority refused to issue you a license or ever revoked, annulled, cancelled, accepted
surrender of, suspended, placed on probation, refused to renew a nursing license, certificate, or multi-state
privilege held by you now or previously, or ever fined, censured, reprimanded, or otherwise disciplined you?
(You may exclude disciplinary actions previously disclosed to the Texas Board of Nursing on an initial or
renewal licensure application.)
4) [ ] No
*In
[ ] Yes
5) [ ] No [ ] Yes
the past 5 years, have you been diagnosed with or treated or hospitalized for schizophrenia or other
psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial personality disorder, or
borderline personality disorder? (You may answer “No” if you have completed and/or are in compliance
with TPAPN for mental illness OR you’ve previously disclosed to the Texas Board of Nursing and have
remained compliant with your treatment regime and have had no further hospitalization since disclosure.)
*In the past 5 years, have you been addicted or treated for the use of alcohol or any other drug? (You may
answer “no” if you have completed and/or are in compliance with TPAPN)
6) I attest that I understand & meet all the requirements to practice for the type of renewal requested, as listed in 22 TAC, §216(CE).
I understand that no one else may submit this form on my behalf and that I am accountable and responsible for the accuracy of any
answer or statement on this form. Further, I understand that it is a violation of the 22 TAC, §217.12(6)(I) and the Penal Code, sec.
37.10, to submit a false statement to a governmental agency.
Date:
Sign:
(SIGNATURE REQUIRED)
*Pursuant to the Occupations Code §301.207, information, including diagnosis and treatment, regarding an individual’s physical or mental
condition, intemperate use of drugs or alcohol, or chemical dependency and information regarding an individual’s criminal history is confidential
to the same extent that information collected as part of an investigation is confidential under the Occupations Code §301.466.
NOTE: IF YOU ANSWERED “YES” TO #1-5 PLEASE REFER TO INSTRUCTIONS
Renewal Form - Over 90 day Delinquent
Revised 10/2011
STATISTICAL CODES
HIGHEST DEGREE
1=
2=
3=
5=
7=
9=
PRIMARY PRACTICE POSITION:
DIPLOMA
ASSOCIATE DEGREE
BACCALAUREATE IN NURSING
MASTERS IN NURSING
DOCTORATE IN NURSING
VOCATIONAL NURSE/PRACTICAL NURSE PROGRAM
EMPLOYMENT STATUS
1=
2=
3=
4=
5=
EMPLOYED IN NURSING FULL TIME
EMPLOYED IN NURSING PART TIME
EMPLOYED IN OTHER FIELD FULL TIME
EMPLOYED IN OTHER FIELD PART TIME
UNEMPLOYED, RETIRED OR INACTIVE
1=
2=
3=
4=
5=
6=
*7 =
*8 =
*9 =
*10 =
11 =
12 =
13 =
14 =
15 =
ADMINISTRATOR OR ASSISTANT
CONSULTANT
SUPERVISOR OR ASSISTANT
FACULTY/EDUCATOR
HEAD NURSE OR ASSISTANT
STAFF NURSE/GENERAL DUTY
NURSE PRACTITIONER
CLINICAL NURSE SPECIALIST
NURSE ANESTHETIST
NURSE MIDWIFE
INSERVICE/STAFF DEVELOPMENT
SCHOOL NURSE
OFFICE NURSE
RESEARCHER
OTHER:________________________________________
* TEXAS BOARD OF NURSING APPROVAL REQUIRED
PRIMARY PRACTICE SETTING:
1=
2=
3=
4=
5=
6=
7=
8=
9=
10 =
11 =
12 =
13 =
14 =
15 =
INPATIENT HOSPITAL CARE
OUTPATIENT HOSPITAL CARE
SCHOOL OF NURSING
COMMUNITY/PUBLIC HEALTH
SCHOOL/COLLEGE HEALTH
SELF-EMPLOYED/PRIVATE PRACTICE
PHYSICIAN OR DENTIST/PRIVATE PRACTICE
RURAL HEALTH CLINIC
FREESTANDING CLINIC
HOME HEALTH AGENCY
MILITARY INSTALLATION
TEMPORARY AGENCY/NURSING POOL
NURSING HOME/EXTENDED CARE FACILITY
BUSINESS/INDUSTRY
OTHER:_________________________________________
PRIMARY SPECIALTY:
1=
2=
3=
4=
5=
6=
7=
8=
9=
10 =
11 =
12 =
13 =
14 =
15 =
16 =
17 =
COMMUNITY/PUBLIC HEALTH
GENERAL PRACTICE
GERIATRICS
OBSTETRICS/GYNECOLOGY
MEDICAL/SURGICAL
PEDIATRICS
PSYCHIATRIC/MENTAL HEALTH/SUBSTANCE ABUSE
ANESTHESIA
EMERGENCY CARE
HOME HEALTH
INTENSIVE/CRITICAL CARE
NEONATOLOGY
ONCOLOGY
OPERATING/RECOVERY CARE
REHABILITATION
OCCUPATIONAL/ENVIRONMENTAL HEALTH
OTHER:_________________________________________
GENERAL INSTRUCTIONS
1. Answer all questions and Sign the form.
2. Attach the appropriate fee and 20 contact hours of continuing education certificates, awarded within two years immediately
preceding the application for relicensure.
3. Once the application has been received in the board’s office, you must allow 10 working days to process a current nursing
license.
4. Must have been employed in Nursing in the last four (4) years or held a valid Texas nursing license within the last four (4) years.
A Licensed Vocational Nurse that has not practiced in the last four years will need to apply for a Six-Month Temporary Permit
and is required to complete a board approved refresher course before the license is reactivated.
5. List name, location, and dates of employment as a Licensed Vocational Nurse with your current employer during the last four
(4) years.
6. Primary state of residence is defined as the state of a person’s declared fixed permanent and principal home for legal purposes;
domicile. Declaring a compact state, other than Texas, will cause your renewal to be rejected since you can practice in Texas
on your declared compact state license. For more information regarding the compact, visit our web site at www.bon.texas.gov
or the National Councils State Board of Nursing’s web site at www.ncsbn.org.
9. For name change, you must submit a copy of legal documentation, e.g., marriage license, notarized statement or divorce decree
which states the name change. Please indicate how the name is to appear on the license.
GENERAL INSTRUCTIONS - Continued
If you answered yes to questions 1-5 of the Eligibility Questions on page 2, you must provide the Board with the following
information:
*QUESTION #1. The Board has determined that criminal behavior is highly relevant to an individual’s fitness to practice nursing. Therefore, all
criminal convictions or deferred orders, prosecution, or adjudication-a determination by a court that is withheld or delayed for a specific time period,
must be reported to the Board. This includes offenses under the law of another state, federal law, or the Uniform Code of Military Justice that
contains elements of criminal conduct. SUBMIT a personal letter of explanation describing each incident, the behavior that led up to the criminal
order and your conduct since the order, and any rehabilitative efforts that have been performed since the order. In addition, SUBMIT the following
documentation for all felonies and for all misdemeanors:
Certified copies of:
1.
charges (indictment, information, or complaint);
2.
disposition of charges (Judgment, Order of Probation, Sentence, and/or Deferred orders); and
3.
evidence that the conditions of the court have been met.
(To obtain this documentation, contact the county clerk in the jurisdiction where the order was issued for misdemeanors; district court clerk
for felonies.)
You may answer “NO” to the question of prior convictions only if you: (a) received a pardon; or (b) were adjudicated as a minor without a finding
of “delinquent conduct”. If you were ever required to register as a sex offender, you must answer “YES”.
If you have questions regarding the outcome of any criminal matter, consult your attorney.
QUESTION #2. The Nursing Practice Act provides that a person’s conduct in violation of the Nursing Practice Act or rules of the board may be
considered as a factor in its deliberations regarding fitness to practice nursing. Therefore, if a licensee or applicant is the subject of a grand jury
or governmental agency investigation, the information regarding conduct or behavior giving rise to the investigation may be relevant in determining
a violation of the Nurse Practice Act or lead to the admissibility of relevant evidence of such violation. If you are the subject of a grand jury or
governmental agency investigation, please SUBMIT the name and address of the investigating entity and an explanation as to the basis of the
investigation.
QUESTION #3. The Board has determined that if any licensing authority has taken disciplinary action against a person for any reason, then those
actions are highly relevant to an individual’s current ability to practice nursing in the state of Texas. If any licensing authority has refused to issue
a license, revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew a license, certificate, or multi
state privilege held by you or previously fined, censured, reprimanded or otherwise disciplined you, SUBMIT the names and address of the
licensing authority who has taken action and a letter explaining the background of the action. Additionally, SUBMIT certified copies of
1. formal charges or allegations supporting the licensure action;
2. final disposition of the licensing authority regarding those formal charges or allegations; and
3. evidence that the conditions of the licensing authority’s order or requirements have been met.
*QUESTION #4. The practice of professional nursing requires current fitness. The Board has identified certain disorders which, if occurring within
the last 5 years, indicate a lack of fitness. The disorders are: schizophrenia and other psychotic disorders, bipolar disorder, paranoid personality
disorder, anti-social personality disorder, or borderline personality disorder. If you have been diagnosed, treated or hospitalized for any of the
above illnesses within the last 5 years, SUBMIT:
1. A report, on letterhead, from your physician, psychiatrist, psychologist or counselor, sent directly to this office, that includes: your diagnosis;
treatments rendered; including current medications; prognosis; cognitive, affective, and emotional stability and continuing after-care
recommendations, including reasonable accommodations needed to safely practice professional nursing, if any; and,
2. Verification of compliance with aftercare recommendations.
*QUESTION #5. The practice of professional nursing requires current sobriety and fitness. If you have been addicted to or treated for the use
of alcohol or any other drug within the last five years, SUBMIT:
1.
2.
3.
4.
verification of treatment for substance abuse sent directly to the Board from the treatment center;
verification of compliance with aftercare recommendations;
evidence of continuing sobriety/abstinence, for example, current support group attendance; and
a personal letter of explanation with sobriety date and plan for relapse prevention.
_________________________________________________________________________________________________________________
*Pursuant to the Occupations Code §301.207, information, including diagnosis and treatment, regarding an individual’s physical or mental
condition, intemperate use of drugs or alcohol, or chemical dependency and information regarding an individual’s criminal history is confidential
to the same extent that information collected as part of an investigation is confidential under the Occupations Code §301.466.
