Fillable Printable Form 50024
Fillable Printable Form 50024
Form 50024
APPLICATION FOR LICENSURE BY EXAMINATION
FOR GRADUATES OF U.S. NURSING SCHOOLS
State Form 50024 (R8 / 9-17)
Approved by State Board of Accounts, 2017
Application fee
FOR OFFICE USE ONLY
Receipt number
Are you applying for a license as a:
Registered Nurse Licensed Practical Nurse
Have you taken the NCLEX examination previously?
Yes, repeat applicant No, first time taking the examination
If Yes, list the date(s) and state where taken:
Name (last, first, middle, maiden)
Street address (number and street or rural route)
Telephone number (include area code)
Date of birth (month, day, year) Place of birth (city and state)
* DO NOT USE THIS APPLICATION IF YOU GRADUATED FROM A NURSING PROGRAM OUTSIDE OF THE UNITED STATES. A FOREIGN GRADUATE
EXAMINATION APPLICATION CAN BE DOWNLOADED AT www.pla.IN.gov .
Check the type of program from which you graduated.
RN PROGRAM Associate Degree (2 year) Baccalaureate Degree (4 year) Diploma (3 year) PN PROGRAM
Name of nursing school
Location (city and state) Date of graduation (month, day, year)
Name of school
Location (city and state)
Date of graduation (month, day, year) If you are not a high school graduate, have you taken and passed the GED? (If yes, submit an official copy of your GED scores.)
Yes No
Do you hold, or have you ever held, a license, certificate, registration or permit to practice nursing and/or any other regulated health occupation?
Yes No
List all states, including Indiana, foreign territories, or countries, in which you hold or have held a license, certificate, registration or permit to practice nursing and/or
any other regulated health occupation.
LICENSE TYPE STATE / COUNTRY / TERRITORY NUMBER
DATE OF ISSUE
(month, day, year)
STATUS
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List other last names you have used
City, state, and ZIP code
( )
Date of enrollment (month, day, year)
Date fee paid (month, day, year)
Issuance date (month, day, year)
License number
DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
E-mail address
NURSING EDUCATION
HIGH SCHOOL EDUCATION
Please check the box to be included on the Health Care Volunteer Registry established by IC 25-22.5-15. (Optional)
Social Security number*
INSTRUCTIONS: 1. The fee for this application is $50.00, payable to the Indiana Professional Licensing Agency, in accordance with 848 IAC 1-1-14.
2. Completed application and fees should be mailed to the address listed in the upper right hand corner of this form.
3. All fees are non-refundable and non-transferable.
4. Please refer to the instructions on our website, www.pla.in.gov, for the licensing requirements.
* This agency is requesting disclosure of your Social Security number in accordance with IC 4-1-8-1; disclosure is mandatory, and this record cannot be processed without it.
Are you the spouse of a member of the military who is assigned to a duty station in Indiana? (Optional)
Yes No
Are you an active duty member of the military? (Optional)
Yes No
Pursuant to IC 12-32-1-5 and IC 12-32-1-6, I swear under the penalty of perjury that: (Please select one of the following.)
I am a United States Citizen. I am a qualified alien (as defined under 8 U.S.C. § 1641).
INDIANA STATE BOARD OF NURSING
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204
Telephone: (317) 234-2043
E-mail: [email protected]
www.pla.IN.gov
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6. Do you have any condition or impairment (including a history of alcohol or substance abuse) that currently interferes, or if left
untreated may interfere, with your ability to practice in a competent and professional manner?
I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.
Date (month, day, year)Signature of applicant
I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional
Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized
representatives in connection with processing my application for licensure as a nurse.
I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to
such inspection or furnishing of any information.
I further authorize the Professional Licensing Agency to disclose to the aforementioned persons, firms, officers, corporations, associations,
organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency and the Indiana State
Board of Nursing from any and all liability in connection with such disclosures.
A photostatic copy of this authorization has the same force and effect as the original.
I hereby swear or affirm that I have read the above statements and agree to the same.
Signature of applicant Date (month, day, year)
PLEASE TAPE YOUR PHOTOGRAPH BELOW (DO NOT STAPLE)
(You must place your signature, the program director’s signature and the school seal on the front of your photograph.)
Pursuant to Section 7 of the Privacy Act of 1974, you are hereby given notice that disclosure of your U.S. Social Security number on your application is
mandatory for the purpose of complying with IC 25-1-5-11, IC 25-1-6-10 and IC 4-1-8-1 which provide that the Indiana Department of Revenue may
obtain Social Security numbers from the Professional Licensing Agency for tax enforcement purposes. In addition, disclosing such number is mandatory
in order for the licensing board or committee to comply with the requirements of the federal National Practitioner Data Bank and the Healthcare Integrity
and Protection Data Bank 42 U.S.C. 1320(a)-7e(b), 5 USC, 552a, 45 CFR Part 60.1, and 45 CFR Part 61.
Failure to disclose your U.S. Social Security number will result in the denial of your application. Application fees are not refundable.
APPLICATION AFFIRMATION
MANDATORY DISCLOSURE OF U.S. SOCIAL SECURITY NUMBER
AUTHORIZATION FOR RELEASE OF INFORMATION
AFFIRMATION
REPEAT APPLICANTS ONLY: If your answer was “Yes” to any of the above questions, and your detailed statement was submitted to the State of
Indiana with your original application and has not changed, please initial here: ____________
You only need to submit additional information if circumstances have changed since you last submitted a detailed statement regarding the above questions.
Page 2 of 3
1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held
in any state or country?
2. Have you ever been denied a license, certificate, registration or permit to practice as a nurse or any regulated health occupation
in any state or country?
3. Except for minor violations of traffic laws resulting in fines, and arrests or convictions that have been expunged by a court,
(1) have you ever been arrested;
(2) have you ever entered into a prosecutorial diversion or deferment agreement regarding any offense, misdemeanor, or felony
in any state;
(3) have you ever been convicted of any offense, misdemeanor, or felony in any state;
(4) have you ever pled guilty to any offense, misdemeanor, or felony in any state; or
(5) have you ever pled nolo contendre to any offense, misdemeanor, or felony in any state?
4. Have you ever been terminated, reprimanded, disciplined or demoted in the scope of your practice as a
nurse or as another health care professional?
5. Have you ever had a malpractice judgment against you or settled any malpractice action?
Yes No
Yes No
Yes No
Yes No
Yes No
If your answer is “Yes” to any of the following, explain fully in a sworn affidavit, including all related details, and provide copies of all relevant arrest or
court documents. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent revocation
of the license or permit issued pursuant to this application.
Yes No
Yes No
Yes No
Yes No
Yes No
CERTIFICATE OF COMPLETION
RN LPN
I hereby certify that__________________________________________________ was admitted
to the ________________________________________________________________ Program
of Nursing located in ______________________________ on __________________________
and completed requirements for graduation on _______________________________________
will/did graduate on ________________________________ . His/Her Social Security number is
________________________________ .
There is evidence in our permanent records that this person has met the requirements as specified
in Indiana law.
DATE:__________________________ SIGNED _____________________________________
Signature
Printed Name
Dean / Director / Designee
SCHOOL
SEAL
APPLICANT: The CERTIFICATE OF COMPLETION form must be completed and sent to the Professional Licensing Agency
by your program of nursing. You will not be declared eligible to take the examination until this form is received by the Agency.
DIRECTOR OF PROGRAM: The applicant cannot be declared eligible to take the examination until this form is received by
the Professional Licensing Agency. CERTIFICATES OF COMPLETION SHOULD NOT BE SENT TO THE PROFESSIONAL
LICENSING AGENCY UNTIL THE APPLICANT HAS COMPLETED THE PROGRAM OF NURSING.
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INDIANA STATE BOARD OF NURSING
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204
Telephone: (317) 234-2043
E-mail: [email protected]
