BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF RE
GISTERED NURSING
PO
Box
944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
ENDORSEMENT APPLICATION FEES & INSTRUCTIONS
ALL FEES ARE NON-REFUNDABLE.
The total fees payable to the Board of Registered Nursing depend on your application method:
Method 1 - US GRADUATE
Method 1 is for applicants who completed a nursing program within the United States or a US territory.
$350.00
APPLICATION:
TEMPORARY LICENSE (OPTIONAL):
FINGERPRINT CARD (IF OUT OF STATE):
$100.00
SUBMIT TOTAL APPLICABLE PAYMENT TO THE BOARD ONLINE VIA BREEZE.
Method 2 is for applicants who completed a nursing program outside of the United States of America
or U.S. territory.
$750.00
APPLICATION:
TEMPORARY LICENSE (OPTIONAL):
FINGERPRINT CARD (IF OUT OF STATE):
$100.00
Method 2 - INTERNATIONAL GRADUATE
(Rev 7/21)
SUBMIT TOTAL APPLICABLE PAYMENT TO THE BOARD ONLINE VIA BREEZE.
For applicants submitting fingerprints by electronic Live Scan, you will pay the appropriate fingerprinting
fees to the Live Scan operator where you have your fingerprints taken (do not submit the fingerprint card
fee to the Board). You must use a Live Scan site located in Cal
ifornia to use this method. The Board will
NOT be able to receive results for Live Scan fingerprints taken at Live Scan locations that are outside of
California.
PLEASE NOTE: there are
two (2) ways to complete the fingerprint requirement:
Electronic Live Scan OR Fingerprint Card (Hard Card)
Please refer to Section 3 of these application instructions for more information on the fingerprint requirement.
$49.00
$49.00
Endorsement Application Requirements Checklist
Applicants must provide the
following:
Appropriate Fees (see Application Fee Schedule).
Online Application for Licensure by Endorsement
Completed fingerprints using either the Live Scan Process or the Applicant Fingerprint Card
(Hard Card) processing method as directed in the INSTRUCTIONS FOR SUBMITTING A
FINGERPRINT CARD. Submit the appropriate non-refundable TOTAL FEE as directed on the
attached Application Fee Schedule.
Completed Verification of License form OR if your board of nursing participates in Nursys®,
visit www.nursys.com to complete a paperless verification online. International graduates must
submit license verification from the board of nursing where the examination was taken. (See
detailed instructions.)
Transcripts sent directly from your school of nursing.
If applicable, documents and/or letters explaining disciplinary action and attesting to
your rehabilitation as directed in Section II of the General Information and Instructions.
For International Graduates only:
A) Send Breakdown of Educational Program for International Nursing Programs form to
our school with the Request for Transcript form. Also, provide the Certified English Translation
for
m to your certified translator if your transcript is not in English. (See Supplemental
Application Instructions for International Graduates.)
B) Submit a copy of your license or diploma that allows you to practice professional nursing in the
country where you were educated. Also, provide copies of your certificates for midwifery and
psychiatric nursing, if applicable.
Board Address & Web Site
Mailing Address: Board of Registered
Nursing P.O. Box 944210
Sacramento, CA
94244-2100
Street Address:
Web Site:
Board of Registered Nursing
1747 North Market Blvd., Suite
150 Sacramento, CA 95834
www.rn.ca.gov
The Nursing Practic
e Act (NPA) is available on the Board’s web site.
Many licensing questions are answered on the web site. Due to the heavy volume of
telephone calls to the Board, we encourage use of the web site to avoid busy signals or
long waits.
(Rev 7/21)
CALIFORNIA BOARD OF REGISTERED NURSING
APPLICATION FOR LICENSURE AS A REGISTERED NURSE
General Information and Instructions
By Endorsement
I. INTRODUCTION
To qualify for endorsement into California as a registered nurse, you must hold a current and active
license in another state or Canada, have completed an educational program meeting all California
requirements, and have passed the national licensure examination or acceptable five-part Canadian
examination. The Canadian Comprehensive Examination is not acceptable. If you do not possess these
qualifications, you must apply for licensure by examination. Please contact the Board of Registered
Nursing at (916) 322-3350 to request an application for examination or download the application from the
Board’s web site at www.rn.ca.gov.
Note: If you are seeking licensure in California as a Licensed Vocational Nurse, please contact the Board
of Vocational Nursing and Psychiatric Technicians at (916) 263-7800. You may also visit their web site at
www.bvnpt.ca.gov.
PLEASE NOTE THE FOLLOWING IMPORTANT ISSUES:
• Processing times may vary, depending on when the Board receives documents from schools,
agencies, and other states or countries. The time to process an application indicating a prior
discipline may take longer than other applications. Delays may also occur with the fingerprint
processing by the Department of Justice (DOJ) and/or the Federal Bureau of Investigation (FBI).
• If you change your name and/or address after submitting an application for licensure, you must
notify the Board immediately in order to receive current information. Applicants are required to
submit legal documentation of a name change to the Board. Examples of acceptable forms of
legal documentation are a birth certificate, marriage certificate, divorce decree, and/or court
documents, social security card or passport. A copy of a driver’s license is not acceptable.
• Pending application files are not public record, therefore an applicant must sign and submit a
release of information before the Board will release information to the public (employers,
relatives, or other third parties).
• Once you are licensed, your address of record must be disclosed to the public upon request,
under California law.
• Applicant fees are earned; therefore, fees are non-refundable even if an applicant is found
ineligible.
(Rev 6/20)
1
II. REPORTING PRIOR DISCIPLINE AGAINST LICENSES
All disciplinary action against an applicant's registered nurse, practical nurse, vocational nurse or
other health care related license or certificate must be reported.
Failure to report prior disciplinary action is considered falsification of application and is
grounds for denial of licensure or revocation of license.
When reporting prior disciplinary action, applicants are required to provide a full written explanation
of: circumstances surrounding the disciplinary action(s) and the date of disciplinary action(s). For
disciplinary proceedings against any license as a RN or any health-care related license; include copies
of state board determinations/decisions, citations and letters of reprimand.
To make a determination in these cases, the Board considers the nature and severity of the offense,
additional subsequent acts, recency of acts or crimes, compliance with court sanctions, and evidence of
rehabilitation.
The burden of proof lies with the applicant to demonstrate acceptable documented evidence of
rehabilitation. Examples of rehabilitation evidence include, but are not be limited to:
• Recent, dated letter from applicant describing the event and rehabilitative efforts or changes in
life to prevent future problems or occurrences.
• Recent and signed letters of reference on official letterhead from employers, nursing instructors,
health professionals, professional counselors, parole or probation officers, Support Group
Facilitators or sponsors, or other individuals in positions of authority who are knowledgeable
about your rehabilitation efforts.
• Letters from recognized recovery programs and/or counselors attesting to current sobriety and
length of time of sobriety, if there is a history of alcohol or drug abuse.
• Submit copies of recent work evaluations.
• Proof of community work, schooling, self-improvement efforts.
All of the above items should be mailed directly to the Board by the individual(s) or agency who is
providing information about the applicant. Have these items sent to the Board of Registered Nursing,
Licensing Unit, P.O. Box 944210, Sacramento, CA 94244-2100.
It is the responsibility of the applicant to provide sufficient rehabilitation evidence on a timely
basis so that a licensing determination can be made. All evidence of rehabilitation must be
submitted prior to being found eligible for licensure.
An applicant is also required to immediately report, in writing, to the Board any disciplinary
action(s) which occur between the date the application was filed and the date that a California
registered nursing license is issued. Failure to report this information is grounds for denial of
licensure or revocation of license.
NOTE: The application must be completed and signed by the applicant under the penalty of perjury.
(Rev 6/20)
2
III. INSTRUCTIONS FOR SUBMITTING A FINGERPRINT CARD OR LIVE SCAN PROCESS
All applicants for licensure by endorsement are required to complete and submit one (1) set of
fingerprints. All requests from the Board of Registered Nursing for background checks of applicants must
be submitted to the Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI) either by
Live Scan or on an Applicant Fingerprint Card (Hard Card). The Applicant Fingerprint Card (Hard Card) or
Request for Live Scan Service Applicant Submission form (BCII 8016) must be submitted in the same
name as shown on your application for endorsement.
The fingerprints remain on file with the California Department of Justice, who provides reports to the
Board of Registered Nursing of any future convictions on an ongoing basis.
There are two (2) methods available for completing the fingerprint requirement:
Method 1 -- Live Scan Process
For licensees residing in California, the Board of Registered Nursing recommends you use Live Scan to
submit your fingerprints in order to shorten the time for your fingerprint process. Licensees must complete
and submit the Request for Live Scan Service Applicant Submission form (BCII 8016) at a Live Scan site.
You may request for a Live Scan form to be sent to you by e-mail by using our online request form at
https://www.dca.ca.gov/webapps/rn/requests.php. Take the form to a Live Scan site within California for
processing. Federal Bureau of Investigations (FBI) guidelines requires applicants to complete a criminal
history background check AFTER they have submitted their application.
Processing Fee for Live Scan Service:
The fee for the Live Scan service varies, so please contact the Live Scan site directly to obtain the correct
information. To see a listing of the California Department of Justice (DOJ) applicant Live Scan agency
locations, fees and hours of operation, go to www.ag.ca.gov/fingerprints/publications/contact.php.
When using the Live Scan process, the fingerprint processing fee must be paid at the Live Scan site
when you provide your live scan fingerprints. Do not send your fingerprint processing fee to the Board.
Please be aware that these processing fees are in addition to the “rolling” fee charged by the Live Scan
operator.
Once your fingerprints have been scanned and you have completed the required sections, the Live Scan
operator will keep one copy and return the second and third copies to you. Typically, the Board receives
results without issue; however if there is an error with receiving your results, the Board may ask you for a
copy of your completed Live Scan form. Submit a copy to the Board only if you are asked to submit a
copy. You may retain the third copy for your records.
Using Live Scan can speed your licensure because the Board receives fingerprint results from this new
technology much quicker than through the manual fingerprint card process. On average, Live Scan
results take 1-2 weeks, while manual fingerprint cards can take 1-2 months. (Processing times at DOJ
and FBI vary.)
Method 2 -- Applicant Fingerprint Card (Hard Card)
You may request for a fingerprint card to be sent to you by using our online request form at https://
www.dca.ca.gov/webapps/rn/requests.php. Applicants must complete all items which are marked by a
black “X” on the card. To facilitate prompt and accurate processing of the fingerprint card by the DOJ and
FBI, type or print legibly in BLACK INK all requested information on the card. If any color other than black
is used, the card will be rejected and another card will have to be completed and submitted.
Use the abbreviations listed below for the physical description items:
• Height (HGT) - Express in feet and inches. Do not use fractions of an inch; round off to the
nearest inch. DO NOT USE THE METRIC SYSTEM. Correct example: 5' 9".
• Weight (WGT) - Express in pounds. Do not use fractions of a pound; round off to the nearest
pound. DO NOT USE THE METRIC SYSTEM. Correct example: 139 lbs.
(Rev 1/19)
3
III.
IV.
V.
INSTRUCTIONS FOR SUBMITTING A FINGERPRINT CARD OR LIVE SCAN PROCESS - (continued)
• Color of EYES - Black
Blue
BLK
BLU
Gray
Green
GRY
GRN
Brown BRN Hazel HZL
• Color of HAIR - Bald
Black
Blonde
Brown
BAL
BLK
BLN
BRN
Gray
Red/ Auburn
Sandy
White
GRY
RED
SDY
WHI
Each applicant MUST have his/her fingerprints imprinted only in BLACK INK on fingerprint card.
Fingerprints should be taken at a local law enforcement agency. There may be a fee for this service. We
advise that you should call first as to a convenient time.
DO NOT FOLD FINGERPRINT CARD. Use a 9" X 12" envelope to return your completed application and
fingerprint card with fees. Write "DO NOT FOLD" on the envelope. If your card is folded, you will need to
complete and submit a new fingerprint card. THIS WILL CAUSE A DELAY IN DETERMINING YOUR
ELIGIBILITY FOR LICENSURE.
Fingerprint Processing Fee for Applicant Fingerprint Card (Hard Card):
The fingerprint processing fee is in addition to the application fee. This fee is non-refundable and is subject
to change by the DOJ and FBI without notice.
The appropriate fingerprint processing fee is payable to the Board of Registered Nursing by check or money
order in U.S. currency. The application fee and fingerprint fee may be combined and submitted to the Board
with one check or money order in U.S. currency. (See Licensure by Endorsement fee schedule.)
There must be a clearance of the fingerprinting requirement before a permanent registered nurse license
will be issued to endorsement applicants.
U.S. SOCIAL SECURITY NUMBER & TAX INFORMATION
Disclosure of your U.S. Social Security Number or individual taxpayer identification number (ITIN)
is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USC section
(c)(2)(C)) authorize collection of your U.S. Social Security Number/ITIN. Your U.S. Social Security Number/
ITIN will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment or
order for family support in accordance with Section 11350.6 of the Welfare and Institutions Code, or for
verification of licensure or examination status by a licensing or examination entity which utilizes a national
examination where licensure is reciprocal with the requesting state. If you fail to disclose your U.S.
Social Security Number/ITIN, your application for initial or renewal license will not be processed.
You will also be reported to the Franchise Tax Board, which may assess a $100 penalty against you.
Questions regarding the Franchise Tax Board should be directed to (800) 852-5711.
ALERT: Effective July 1, 2012, the Board of Registered Nursing is required to deny an application for
licensure and to suspend the license/certificate/registration of any applicant or licensee who has
outstanding tax obligations due to the Franchise Tax Board (FTB) or the State Board of Equalization
(BOE) and appears on either the FTB or BOE's certified lists of top 500 tax delinquencies over $100,000.
(AB 1424, Perea, Chapter 455, Statutes of 2011).
TEST OF ENGLISH AS A FOREIGN LANGUAGE (TOEFL)
Proof of passage of an English comprehension examination if you are from a non-English speaking
country or did not take your country's licensing examination in English. Passage of the Test of English as a
Foreign Language (TOEFL) is acceptable. It is suggested that if you decide to take the TOEFL, you should
apply as soon as possible as it takes several months from the time of filing until your TOEFL results are
received. TOEFL is located at P.O. Box 6151, Princeton, NJ 08541-6151; phone number (609) 771-7100.
You may also visit their web site at www.toefl.org.
(Rev 1/19)
4
VI. GENERAL INFORMATION ON LICENSURE BY ENDORSEMENT
Endorsement is the licensure method for registered nurses who have previously been licensed in another
state in the United States and for some Canadian registered nurse licensees. To qualify for licensure by
endorsement, you must meet all of the following requirements:
1. Completion of the nursing program in an accredited school of professional nursing which meets
all of California’s educational requirements. If you are deficient in any requirement, you must
make up the deficiency prior to becoming licensed.
2. Passage of the National Council Licensure Examination (NCLEX) or the State Board Test Pool
Examination (SBTPE) for Registered Nurses in the United States, or the five-part licensing
examination in Canada. The Canadian Comprehensive Examination is not acceptable. An
English comprehension examination is required if you did not take the Canadian examination in
English. Passage of the Test of English as a Foreign Language (TOEFL) is acceptable for
English competency. TOEFL is located at P.O. Box 6151, Princeton, NJ 08541-6151; phone
number (609) 771-7100. You may also visit their web site at
www.toefl.org.
International graduates who have not passed one of the acceptable licensing examinations are
not eligible for licensure by endorsement and should contact the Board at (916) 322-3350 to
request an application for licensure by examination or download the application from the Board’s
web site at www.rn.ca.gov
.
3. Possession of a current and active license from another state in the United States or from
Canada. (If you do not have a current license in the other state, it must be updated prior to
California licensure.)
VII. VERIFICATION OF LICENSE
There are two (2) methods available for obtaining license verification:
Method 1 – Verification of License form
The state board from which you are submitting proof of clear, current and active RN licensure must
complete the enclosed Verification of License form. Be sure to include the processing fee that is
required by that state.
OR
Method 2 – Nursys® License Verification Request Application
If you are licensed as an RN in a state that is a member of the Nursys® verification system, visit
www.nursys.com to complete the online verification request application process. Nursys.com applicants
can pay by credit card using the secure and private payment system. Once the application is complete
and the credit card payment approved, the verification is posted immediately. The fee for verification of
an RN license is $30.
For International Graduates: In addition to obtaining license verification from the state where you hold a
current and active license, you must also obtain verification of passage of the appropriate licensing
examination from the board of nursing where you took the examination (NCLEX-RN, SBTPE, or five-part
licensing examination in Canada).
No telephone verifications will be made. Official license verification must be received in writing from
the other state board before a temporary or permanent license can be issued by this board.
(Rev 1/19)
5
VIII. REQUEST FOR TRANSCRIPT
Mail the Request for Transcript form to your nursing school(s) with the fee required by the school. The
official transcripts must include all completed coursework and reflect the degree awarded and
date conferred. Transcripts are not accepted from applicants or if stamped “issued to student.”
Transcripts are required from all colleges you attended that reflect courses required for a degree in
nursing, including general education course requirements and all nursing courses.
IX. TEMPORARY LICENSE
The Board may issue a Temporary License to practice nursing for a period of six months, allowing an
applicant to work pending issuance of a permanent RN license.
Temporary Licenses cannot be issued until the processing of the fingerprint card or live scan has been
completed by the Department of Justice (DOJ) and Federal Bureau of Investigation (FBI) and the Board
has been notified of the results.
To qualify for a Temporary License, the endorsement applicant must submit:
• Appropriate Fees.
• Application for Licensure by Endorsement including a U.S. Social Security and the request
for a Temporary License.
• One completed Fingerprint Card (Hard Card) or second copy of the Live Scan Service
Applicant Submission form (BCII 8016). Additionally, before a Temporary License can be issued,
fingerprint results from the DOJ and the FBI must be received and processed by the Board.
• Verification of License form from the other state(s) or Canada which must be received by the
Board via: sealed envelope from State Board of Nursing or a Nursys® Verification Request
Application if you are licensed in a state that is a member of the Nursys® verification system as
proof of a clear, active, and current RN license.
• If educated outside of the United States, you must submit official transcripts which include all
completed coursework, the degree awarded and date conferred. Transcripts are not
accepted from applicants or if stamped “issued to student.” Transcripts are required from all
colleges you attended that reflect courses required for a degree in nursing, including general
education c
ourse requirements and all nursing courses. Transcripts must be reviewed and
approved prior to the issuance of a Temporary License.
If you have not received notification of permanent licensure approximately four weeks prior to the
expiration of your Temporary License, contact the Board at (916) 322-3350 for instructions on how to
apply for a second Temporary License.
X. ADVANCED PRACTITIONERS/PUBLIC HEALTH NURSES
In order to use the title or hold yourself out as a nurse practitioner, psychiatric/mental health nurse, nurse
midwife, nurse anesthetist, clinical nurse specialist or public health nurse, California law requires
registered nurses to be certified by the Board. If you wish to practice in one of these areas, please
request the applicable additional application for certification.
(Rev 1/19)
6
XI. ACTIVE DUTY MILITARY SPOUSES OR PARTNERS RECEIVE EXPEDITED REVIEW
The board is required to expedite the licensure process for an applicant whose spouse or partner is an
active duty member of the U.S. Armed Forces and meets other criteria. (Business and Professions Code
section 115.5.) If you would like to be considered for this expedited review and process, please answer
the following questions and provide required documentation.
1. Are you married to, or in a domestic partnership or other legal union with, an active duty member of
the Armed Forces of the United States who is assigned to a duty station in California under official
active duty military orders?
If “yes,” please attach a copy of the marriage certificate or certified declaration/registration of
domestic partnership filed with the Secretary of State AND military orders establishing duty
station in California. For other forms of “legal union” not recognized by California, you may
submit other documentary evidence of legal union issued by the State that recognizes your legal
union for consideration by the board in meeting this requirement.
2. Do you hold a current license in another state, district, or territory of the United States in the
profession or vocation for which you seek licensure from the board?
If “yes,” please attach a copy of the current license in another state, district, or territory of the
United States.
NOTE: Expediting your application does not exempt you from meeting all licensure requirements.
XII.
HONORABLY DISCHARGED MEMBERS OF THE U.S. ARMED FORCES RECEIVE EXPEDITED REVIEW
Notwithstanding any other law, on and after July 1, 2016, a board within the department shall expedite, and
may assist, the initial licensure process for an applicant who supplies satisfactory evidence to the board
that the applicant has served as an active duty member of the Armed Forces of the United States and was
honorably discharged (Business and Professions Code section 115.4.).
If you would like to be considered for this expedited review and process, please provide the following
documentation with your application:
1. Report of Separation form.
The report of separation form issued in most recent years is the DD Form 214, Certificate of Release or
Discharge from Active Duty. Before January 1, 1950, several similar forms were used by the military
services, including the WD AGO 53, WD AGO 55, WD AGO 53-55, NAVPERS 553, NAVMC 78PD and the
NAVCG 553.
Information shown on the Report of Separation may include the service member's date and place of entry
into active duty, date and place of release from active duty, last duty assignment and rank, military job
specialty, military education, total creditable service, separation information, etc.
(Rev 1/19)
7
XIII. EXPEDITED LICENSURE PROCESS FOR REFUGEES, ASYLEES, AND HOLDERS OF SPECIAL
IMMIGRANTS VISAS (SIVS)
Individuals seeking an expedited licensure process as required by Business and Professions Code section
135.4. Beginning January 1, 2021, individuals in the following categories may have their applications
expedited:
1.
Refugees pursuant to section 1157 of title 8 of the United States Code;
2.
Those granted asylum by the Secretary of Homeland Security or the Attorney General of the United
States pursuant to section 1158 of title 8 of the United States Code; or,
3.
Individuals with a special immigrant visa that have been granted a status pursuant to section 1244
of Public Law 110-181, Public Law 109-163, or section 602(b) of title VI of division F of Public Law
111-8.
In order to receive the expedited licensure process, individuals must provide evidence of their refugee,
asylee, or special immigrant visa status when submitting their application package. Documentation below
are examples that can be used:
Form I-94, Arrival/Departure Record, with an admission class code such as “RE” (Refugee) or “AY”
(Asylee) or other information designating the person a refugee or asylee.
Special immigrant visa that includes the classification codes of “SI” or “SQ.”
Permanent Resident Card (Form I-551), commonly known as a “Green Card,” with a category
designation indicating that the person was admitted as a refugee or asylee.
An order from a court of competent jurisdiction or other documentary evidence that provides
reasonable assurance that the applicant qualifies for expedited licensure.
Failure to provide documentation may result in a delay in expediting the application review.
Please note that this does not mean a license/registration must be issued, but simply that the process will
be expedited.
(Rev 1/21)
8
State: City:
Name: (Last, First, Middle)
Zip Code:
PART I: To be completed by APPLICANT and forwarded to appropriate licensing boards.
Previous Names: (Including Maiden)
Current Street Address of Record:
Name as it Appeared on Original License:
(Last, First, Middle) Date of Birth: (Month/Day/Year)
U.S. Social Security Number or
Individual Taxpayer ID Number
:
State of Current Licensure: Issue Date of Current License: Current License Number:
State of Original Licensure: Issue Date of Original License: Original License Number:
I hereby authorize all identified Boards of Nursing to release my licensure data to the California Board of Registered Nursing.
Signature: _______________________________________________________________________ Date: ______________________
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
VERIFICATION OF LICENSE
1. Send this form to the State Board of Nursing where you have a current and active license. The board of nursing may require a processing fee.
If you are licensed as an RN in a state that is a member of the Nursys verification system, visit www.nursys.com to complete the online verification
request application process.
2. INTERNATIONAL GRADUATES: Send form to the state of current license. If you took the examination in a different state, make a copy
of this form and send the form to that state also.
PART II: To be completed by licensing board and sent to the California Board of Registered Nursing listed at the top of this form.
This is to certify that this applicant was issued a license number to practice as a registered nurse:
Applicant Name: _______________________________________________________ Date Issued: ____________________
License Number: ____________________ Expiration Date: _________________
Licensed by: Endorsement Examination Waiver
Current Licensure Status: Active Inactive Lapsed
Has license ever been REVOKED, SUSPENDED, placed on PROBATION, or DISCIPLINED in any way? Yes No
If yes, please attach certified documents. Reinstated? Yes No
Date Reinstated: ________________
Is there any PENDING disciplinary action or pending investigation against this licensee? Yes No
If yes, please attach information.
Name of Professional Nursing Program:
Approved by State?
Yes No
Graduated from:
High School H.S. Equivalency 10th Grade
Location: (City, State/Country)
Graduation Date:
Type of Nursing Program
ADN DIP BSN MSN Other
Examination Passed:
NCLEX-RN SBTPE Canadian Five-Part Taken in English? Yes No
Scores: SBTPE/Canadian
Medical Surgical Obstetric Pediatric Psychiatric
NCLEX-RN ___________ _______ ________ ________ ________ ________
Series or Exam Date:
Signature: _________________________________________________________________ Title: ______________________________
Board of Nursing: ____________________________________________________________ Date: _____________________________
[BOARD SEAL]
(Rev 1/19)
INDIVIDUAL TAXPAYER ID NUMBER:
LAST NAME: FIRST NAME: MIDDLE NAME:
ADDRESS: Number and Street DATE OF BIRTH:
(Month/Day/Year)
City State Country Postal/Zip Code U.S. SOCIAL SECURITY NUMBER or
PREVIOUS NAMES: (Including Maiden)
NAME OF PROFESSIONAL REGISTERED NURSING SCHOOL: YEARS ATTENDED:
LOCATION: City State Country Postal/Zip Code YEAR GRADUATED:
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
REQUEST FOR TRANSCRIPT
TO APPLICANT: Send this form to your basic school(s) of nursing. If you need to contact more than one school, this form may be reproduced.
Transcripts are required from each school where nursing requirements or general education courses were completed. Transcripts must include all
completed coursework, clinical practice of training and reflect the degree awarded. Your school may require a processing fee.
A. TO BE COMPLETED BY APPLICANT
The above applicant has applied for a license to practice as a registered nurse in California. Please provide the following
information and attach a complete official transcript. Please mail to the Board of Registered Nursing at the above address.
DO NOT SIGN OR SUBMIT THIS FORM PRIOR TO COMPLETION DATE OF THE REGISTERED NURSING PROGRAM.
ENTRANCE DATE:
DATE DIPLOMA/ DEGREE AWARDED:
DATE NURSING REQUIREMENTS COMPLETED:
If degree received prior to entering nursing program, list name of school and type of degree:
NAME OF SCHOOL:
TYPE OF DEGREE:
SIGNATURE OF SCHOOL OFFICIAL: ______________________________________ DATE: __________
TITLE: __________________________________
SIGNATURE OF APPLICANT: ___________________________________________ DATE: ___________
B. TO BE COMPLETED BY THE OFFICE OF THE SCHOOL OFFICIAL RELEASING TRANSCRIPTS
NOTE: ALL INTERNATIONAL NURSING PROGRAMS: Please include Breakdown of Educational Program for International
Nursing Programs form. Transcripts received from the school in a foreign language will require an English translation by a certified
translator or translation service. The original foreign language transcript and the English translation of the transcript
must both be sent to the Board of Registered Nursing.
(Rev 1/19)
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
TO: ALL APPLICANTS EDUCATED OUTSIDE THE UNITED STATES
FROM: CALIFORNIA BOARD OF REGISTERED NURSING
SUBJECT: SUPPLEMENTAL APPLICATION INSTRUCTIONS
Applicants who have graduated from schools outside the United States may face unique
problems as they attempt to complete their application for California licensure. This document
is intended to provide suggestions and information to assist with those special problems.
Application Submission
The Board strongly recommends that you try to ensure that your application, school
transcript(s), and all other required documents reach the Board as soon as possible to prevent
delays in issuing an interim permit, temporary or permanent license. In some instances, delays
and difficulties may be encountered when requesting documentation for those who have
graduated from an international nursing program.
In many cases, the Board must obtain additional information from the school in order to clarify
course content and/or curriculum requirements. We may also request clarification for the
amount of theory and clinical training completed. Also, additional information is required if the
applicant is the first graduate from their school of nursing to apply for California licensure. The
schools curriculum, catalogs and/or other documents may be requested to evaluate the
programs content (these items are in addition to the individuals nursing transcripts.)
Obtaining additional information from the school may take from one to six months, depending on
the responsiveness of the school and allowing for mail time. All requirements must be met in
order for an interim permit or permanent license to be issued.
Requesting Transcripts
When submitting the “Request for Transcript” form to your school of nursing, please include the
“Breakdown of Educational Program for International Nursing Programs” form. Both forms do
not take the place of a complete, official transcript. The transcripts should include all completed
coursework (both theoretical and clinical practice). All training documents must come directly
from the school of nursing. Training documents from applicants are not acceptable.
Commission of Graduates of Foreign Nursing Schools (CGFNS)
The Board does not require applicants to pass the Commission on Graduates of Foreign
Nursing Schools (CGFNS) examination in order to be licensed in California. Although, if you
have been evaluated by CGFNS, the Board will accept official copies of your nursing transcripts
(including the clinical portion of your training) from this organization. Requests must be made in
writing to CGFNS by contacting them at (215) 222-8454 or 3600 Market Street, Suite 400,
Philadelphia, PA 91904-2651. You may also visit their website at
www.cgfns.org.
(Rev 1/19)
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.a.gov
Translation of International Academic Credentials
For the Board to fairly evaluate compliance with California requirements, any applicant with non-English,
non-U.S. academic credentials must provide both 1) original, certified transcripts and 2) certified
translations of those original transcripts and academic documents. Original language transcripts must
be forwarded directly from the school of nursing and sent directly to the Board (photocopies are
not accepted). When requesting official transcripts and academic documents, an applicant whose
education was completed at an institution in a bilingual country where English is one of the official
languages, may be able to avoid the necessity of arranging for a translation by asking the school to
generate an English language version of the transcript. Please note that in this instance, the original
language transcript must accompany the English translation and be forwarded directly to the Board.
Applicants must have their transcripts translated by an independent, professional translator who is not
related to the applicant. Each translator must provide an original declaration with each translation
attesting to his/her fluency in the particular language and certifying under penalty of perjury that the
translation is complete and accurate to the best of the translator’s ability and knowledge. (See attached
form.) The Board refers applicants with non-English academic credentials to one of the following
sources for translation:
1. Translator accredited by the American Translators Association (ATA): The ATA accredits
individual translators by examination. Although accreditation is available only to individuals, ATA
membership includes not only individuals but also companies that employ accredited translators.
An accredited translator must sign the translation and declaration in the presence of a Notary
Public, unless the translation is a service provided by a known translation agency which affixes
the document with its own official seal. ATA membership includes accredited translators residing
in the US, Canada, Mexico, and overseas. Although the ATA does not make referrals, a listing of
accredited translators and member companies is available through its web site at
www.atanet.org. The ATA may be reached by phone at 703-683-6100 or by e-mail at
2. Certified or registered court interpreter: Some state court systems offer examinations for
certification or registration of court interpreters. In California, the Judicial Council is charged with
these functions. Information on court interpreters is available through the Judicial Council at 415-
865-7530. General information is available via its web site, www.courtinfo.ca.gov.
The Judicial
Council has contracted with Cooperative Personnel Services (CPS) for examination and
certification of Certified Administrative Hearing and Medical Interpreters. A master list of these
interpreters is available at the CPS web site, www.cps.ca.gov, or telephone at 916-263-3600.
The court interpreter must sign the translation and declaration in the presence of a Notary Public.
Applicants residing outside California but within the United States may call the National Center for
State Courts at 757-259-1517 for information on certification and registration of interpreters in
other states.
Applicants who present documents in a language for which accredited translators or certified/registered
court interpreters are not readily available may require special assistance. The usual next step is to
inquire at the nearest consulate representing the nation in which the documents originated.
(Rev 1/19)
LAST NAME: FIRST NAME: MIDDLE NAME:
PREVIOUS NAMES:
(Including Maiden) DATE OF BIRTH: (Month/Day/Year)
____________________________________________________________
____________________________________________________________
____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________
___________________________________________
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
CERTIFIED ENGLISH TRANSLATION
Name of Applicant:
TO BE COMPLETED BY TRANSLATOR
I, ____________________________________________, solemnly declare, under penalty
of perjury, that to the best of my knowledge and belief the English-language translation of
the _______________________________________ language documents named below are
true, accurate and complete.
Please list translated documents below: (i.e. transcripts, license, diploma, curriculum, etc.)
These documents have been translated by: _____________________________________________
(Print Name)
Please list translator’s qualifications, certifications and accreditations below:
I certify, under penalty of perjury under the laws of the State of California, that all above information
provided is true, correct and complete and that this declaration is executed at
_____________________________________________________ this date____________________.
(City/State or Country)
Name and Address of Translation Agency: __________________________________________
Telephone Number:
______________________________________
Web Site: ______________________________________
Signature of Translator
(Rev 1/19)
STUDENT’S LAST NAME: FIRST NAME: MIDDLE NAME:
DATE OF BIRTH:
(Month/Day/Year) PREVIOUS NAMES: (Including Maiden) HIGH SCHOOL GRADUATION: (Year)
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
BREAKDOWN OF EDUCATIONAL PROGRAM FOR INTERNATIONAL NURSING PROGRAMS
PRINT OR TYPE
NAME AND LOCATION OF PROFESSIONAL REGISTERED NURSING SCHOOL:
ENTRANCE DATE: GRADUATION DATE:
All of the information requested on this form must be submitted including complete official transcript(s) along with the course
description(s)** stated below. Failure to submit all requested documents will result in application processing delays.
COURSE
NUMBER or TITLE
THEORY HOURS
OF INSTRUCTION
(Total Hours)
SKILLS, LAB or
SIMULATION
HOURS OF
INSTRUCTION AT
SCHOOL
(Total Hours)
CLINICAL
PRACTICE HOURS
OF INSTRUCTION
IN HOSPITAL
(Total Hours)
WRITTEN & ORAL
COMMUNICATIONS
GENERAL PSYCHOLOGY
SOCIAL SCIENCE
ANATOMY & PHYSIOLOGY
MICROBIOLOGY
MEDICAL NURSING **
SURGICAL NURSING **
OBSTETRIC NURSING
PEDIATRIC NURSING
PSYCHIATRIC NURSING
** Send course description(s) attached to this form showing evidence of geriatric content in these nursing areas.
Failure to submit course description(s) will result in delays in processing the application.
SIGNATURE OF SCHOOL OFFICIAL: ______________________________________ DATE: _________
TITLE: _____________________________________________
(SCHOOL OR HOSPITAL SEAL/STAMP)
(Rev 1/19)
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
INFORMATION COLLECTION AND ACCESS
The Information Practices Act, Section 1798.17 Civil Code, requires the following information to be
provided when collecting information from individuals.
Agency Name:
BOARD OF REGISTERED NURSING
Title of official responsible for information maintenance:
EXECUTIVE OFFICER
Address: Telephone Number:
P.O. BOX 944210, SACRAMENTO, CA 94244-2100 (916) 322-3350
Authority which authorizes the maintenance of the information:
SECTION 30, SECTION 2732.1(a), BUSINESS AND PROFESSIONS CODE
ALL INFORMATION IS MANDATORY.
The consequences, if any of not providing all or any part of the requested information:
FAILURE TO PROVIDE ANY OF THE REQUESTED INFORMATION WILL RESULT IN THE
APPLICATION BEING REJECTED AS INCOMPLETE.
The principal purpose(s) for which the information is to be used:
TO DETERMINE ELIGIBILITY FOR LICENSURE. YOUR U.S. SOCIAL SECURITY NUMBER/ITIN
WILL BE USED FOR PURPOSES OF TAX ENFORCEMENT, CHILD SUPPORT ENFORCEMENT
AND VERIFICATION OF LICENSURE AND EXAMINATION STATUS. SECTION 30 OF THE
BUSINESS AND PROFESSIONS CODE AND PUBLIC LAW 94-455 (42 USC section (c)(2)(C))
AUTHORIZE COLLECTION OF YOUR U.S. SOCIAL SECURITY NUMBER/ITIN. IF YOU FAIL TO
DISCLOSE YOUR U.S. SOCIAL SECURITY NUMBER/ITIN, YOU WILL BE REPORTED TO THE
FRANCHISE TAX BOARD, WHICH MAY ASSESS A $100 PENALTY AGAINST YOU. YOUR
NAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLIC
UPON REQUEST IF AND WHEN YOU BECOME LICENSED.
Any known or for
eseeable interagency or intergovernmental transfer which may be made of the
information:
POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES AND
REPORTING U.S. SOCIAL SECURITY NUMBER/ITIN TO THE FRANCHISE TAX BOARD OR
FOR CHILD SUPPORT ENFORCEMENT PURPOSES PURSUANT TO SECTION 30 OF THE
BUSINESS AND PROFESSIONS CODE.
EACH INDIVIDUAL HAS THE RIGHT TO REVIEW THE FILES ON RECORDS MAINTAINED ON
THEM BY THE AGENCY, UNLESS THE RECORDS ARE EXEMPT FROM DISCLOSURE.
(Rev 1/19) 1
MANDATORY REPORTER
Under California law each person licensed by the Board of Registered Nursing is a “Mandated
Reporter” for child abuse or neglect purposes. Prior to commencing his or her employment, and
as a prerequisite to that employment, all mandated reporters must sign a statement on a form
provided to him or her by his or her employer to the effect that he or she has knowledge of the
provisions of Section 11166 and will comply with those provisions.
California Penal Code Section 11166 requires that all mandated reporters make a report to an
agency specified in Penal Code Section 11165.9 [generally law enforcement agencies] whenever
the mandated reporter, in his or her professional capacity or within the scope of his or her
employment, has knowledge of or observes a child whom the mandated reporter knows or
reasonably suspects has been the victim of child abuse or neglect. The mandated reporter must
make a report to the agency immediately or as soon as is practicably possible by telephone, and
the mandated reporter must prepare and send a written report thereof within 36 hours of receiving
the information concerning the incident.
Failure to comply with the requirements of Section 11166 is a misdemeanor, punishable by up to
six months in a county jail, by a fine of one thousand dollars ($1,000), or by both imprisonment
and fine.
For further details about these requirements, consult Penal Code Section 11164, and subsequent
sections.
(Rev 1/19) 2
