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Free New York Nurse 1 Form

The New York Nurse 1 form is a crucial document required for individuals seeking licensure as either a Registered Professional Nurse or a Licensed Practical Nurse in New York State. This form must be completed and submitted along with the appropriate fee to the Office of the Professions to initiate the licensing process. It is essential for applicants to provide accurate information and adhere to all instructions to avoid delays in their application review.

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The New York Nurse 1 form is a critical document for anyone seeking licensure as a Registered Professional Nurse or a Licensed Practical Nurse in New York State. This form serves as the first step in the application process, requiring applicants to provide essential personal information, including their social security number, contact details, and educational history. A fee of $143 must accompany the submission, which covers both the application and the first registration period. Accuracy is paramount; applicants must ensure that their name matches exactly across various documents to avoid delays in testing authorization. Additionally, the form includes a series of questions regarding criminal history, previous licensure attempts, and child support obligations, all of which must be answered truthfully. Notably, applicants are required to have their affidavit notarized, reinforcing the importance of honesty in this process. Furthermore, specific training requirements, such as child abuse identification and infection control training, must also be documented. As applicants navigate this complex form, they must pay close attention to detail to ensure a smooth licensure process and ultimately join the ranks of New York's nursing professionals.

Similar forms

Nurse Form 2: Similar to Nurse Form 1, this document is used for licensure applications but specifically focuses on registered nurses who have completed additional educational requirements or who are applying for a different level of licensure.
Nurse Form 3: This form is utilized for license verification purposes. It requires applicants to provide details of their previous nursing licenses, ensuring that all credentials are accurately reported.
Nurse Form 4: This document is similar in that it gathers information about continuing education requirements for nurses, ensuring they remain compliant with state regulations.
Nurse Form 5: This form is for applicants seeking a temporary permit to practice nursing while their full licensure application is being processed, paralleling the urgency found in the Nurse Form 1.
Nurse Form 6: Like Nurse Form 1, this document is used for those applying for licensure by endorsement from another state, requiring a similar level of detailed personal and professional history.
Application for Child Support Certification: This form is related to the child support obligations that applicants must disclose, much like the child support section in the Nurse Form 1.
Background Check Authorization Form: This document is necessary for conducting criminal background checks, similar to the sections in Nurse Form 1 that inquire about past legal issues.
Educational Verification Form: This form collects information about educational credentials, akin to the educational history sections in Nurse Form 1, ensuring that all educational achievements are documented.
Affidavit of Professional Conduct: This document requires applicants to affirm their professional behavior, similar to the affidavit section in Nurse Form 1 where applicants declare the truthfulness of their application.

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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

$143

Licensed Practical Nurse

$143

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.

Social Security Number

2. Birth Date

Month

Day

Year

(Leave this blank if you do not have a U.S. Social Security Number)

Print Name

Last

First

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.

Mailing Address

Home or

Business

Area Code

Phone

(You must notify the Department promptly of any address or name changes)

Email Address (please print clearly)

Line 1

Home or

Business

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

Do you have a CGFNS record?

Yes

If "yes", enter your CGFNS Number:

Name as it appears on degree or other credentials (if different from above)

Have you ever applied for New York State licensure in any profession?

Yes

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

Yes

(felony or misdemeanor) in any court?

11.

Are criminal charges pending against you in any court?

Yes

12.

Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled,

Yes

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?

Yes

14.

Has any hospital, licensed facility or clinical laboratory restricted or terminated your professional training,

Yes

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?		Yes			No
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

City

State/Province

Country

Number of years attended

Attendance from

Completion date

mo.

yr.

mo.

yr.

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.

Name of School

City

State/Province

Country

Number of years attended

Attendance from

Completion date

mo.

yr.

mo.

yr.

mo.

yr.

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.

Name of School

City

State/Province

Country

Major/Concentration

Number of years attended

Attendance from

mo.

yr.

mo.

yr.

Title of Degree/Diploma/Certificate awarded (in original language)

Still in progress

Date Degree/Diploma/Certificate awarded

mo.

yr.

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.

Name of School

City

State/Province

Country

Major/Concentration

Number of years attended

Attendance from

mo.

yr.

mo.

yr.

Title of Degree/Diploma/Certificate awarded (in original language)

Still in progress

Date Degree/Diploma/Certificate awarded

mo.

yr.

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.

State or Territory*	Profession	Exam Name	Exam Date	If Granted, License No.

State or Territory*	Profession	Exam Name	Exam Date	If Granted, License No.

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.

Yes

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

Common mistakes

Filling out the New York Nurse 1 form can be a straightforward process, but many applicants make common mistakes that can delay their application. One significant error is failing to ensure that the name on the application matches exactly with the name on other documents, such as photo identification and the NCLEX application. Any discrepancies can lead to delays in authorization to test, which can be frustrating and costly.

Another frequent mistake is neglecting to complete all required sections of the form. Each question must be answered, and all requested information must be provided. Leaving sections blank or failing to provide necessary details will result in an incomplete application, leading to further delays in processing.

Many applicants also overlook the importance of notarization. The affidavit section of the form requires a signature in the presence of a Notary Public. Failing to have this step completed can result in the application being rejected, requiring the applicant to restart the process.

Providing incorrect or outdated contact information is another common pitfall. Applicants must ensure that the telephone number and email address listed are current. This information is crucial for the Department to reach out regarding any updates or issues with the application.

Some individuals mistakenly assume that the application fee is refundable. However, it is essential to understand that the application fee of $70 is non-refundable. Knowing this can help applicants budget appropriately and avoid confusion later in the process.

In addition, applicants often forget to submit supporting documents when required. For instance, if an applicant has previously held a license or has a CGFNS record, they must provide the necessary documentation along with the application. Missing these documents can lead to further complications and delays.

Lastly, not keeping track of changes during the application process can lead to problems. If any answers to the application questions change while the application is pending, the applicant must notify the Division of Professional Licensing Services immediately. Failing to do so can result in significant setbacks.

More About New York Nurse 1

What is the New York Nurse 1 form?

The New York Nurse 1 form is an application for licensure as a Registered Professional Nurse or a Licensed Practical Nurse in New York State. This form must be completed by all applicants seeking to obtain a nursing license. It requires detailed personal information, educational history, and answers to specific questions related to professional conduct and criminal history.
What fees are associated with the New York Nurse 1 form?

To submit the New York Nurse 1 form, applicants must pay a total fee of $143. This amount includes a $70 application fee and a $73 fee for the first registration period. It's important to note that the application fee is non-refundable, so applicants should ensure all information is accurate before submission.
How should I complete the New York Nurse 1 form?

Applicants must fill out the form using ink (either pen or printer). It is crucial to answer all questions completely and accurately. Missing information can lead to delays in processing your application. Additionally, the form requires a notarized signature, which means you must sign it in front of a Notary Public.
What happens if my name does not match exactly on all documents?

It is essential that the name on your application matches exactly with the name on your photo identification and your NCLEX application. If there are discrepancies, it may delay your authorization to test (ATT). In some cases, you might not be allowed to take the exam at the scheduled time, which could lead to additional fees. Therefore, ensure that all names are consistent across all documents.

Misconceptions

Misconception 1: The application fee is refundable.

The application fee of $143, which includes both the application fee and the first registration period fee, is non-refundable. This means that once the fee is paid, it cannot be returned, regardless of the outcome of the application.

Misconception 2: Only the application form needs to be completed.

All applicants must provide detailed information about their educational background, including schools attended and degrees earned. Incomplete information may result in the application being considered incomplete.

Misconception 3: Name discrepancies are not a significant issue.

It is crucial that the name on the application matches exactly with the name on photo identification and the NCLEX application. Any discrepancies can lead to delays in testing authorization and may incur additional fees.

Misconception 4: Criminal history does not need to be reported unless convicted.

Applicants must disclose any criminal charges that are pending, as well as any past convictions. This includes felonies and misdemeanors. Failing to report such information can affect the application process.

Misconception 5: Citizenship status is not a requirement for licensure.

Federal law restricts the issuance of professional licenses to U.S. citizens or qualified aliens. Applicants must complete the citizenship section of the form and provide the necessary documentation to confirm their status.

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Key takeaways

When filling out the New York Nurse 1 form, there are several important points to keep in mind to ensure a smooth application process. Here are key takeaways:

Complete All Sections: Ensure that every section of the form is filled out completely. Missing information can lead to delays in processing your application.
Exact Name Matching: The name on your application must match exactly with your photo ID and NCLEX application. Any discrepancies can cause significant delays.
Notarization Required: You must sign and date the affidavit in front of a Notary Public. This step is essential for the validity of your application.
Application Fee: The total fee for submitting the application is $143. This includes a $70 application fee and a $73 fee for your first registration period. Remember, the application fee is non-refundable.
Disclosure of Criminal History: Be honest when answering questions about your criminal history. If you answer "yes" to any of the relevant questions, you must provide a detailed explanation and any supporting documents.
Child Support Certification: You must certify your child support obligations. If you are in arrears, this could affect your ability to obtain a license.
Education Verification: Provide complete details about all educational institutions attended. This includes elementary, high school, and nursing programs. Incomplete information may result in an incomplete application.

By following these guidelines, you can help ensure that your application for licensure is processed efficiently and without unnecessary complications.

New York Nurse 1: Usage Guide

Completing the New York Nurse 1 form is an essential step for individuals seeking licensure as a nurse in New York State. After filling out the form, it must be submitted along with the required fee to the Office of the Professions. Ensure that all information is accurate and complete to avoid delays in processing.

Gather your personal information, including your Social Security Number and birth date. Leave the birth date blank if you do not have a U.S. Social Security Number.
Clearly print your full name (last, first, and middle) as it appears on your identification.
Provide your mailing address. Indicate whether it is a home or business address.
Include your daytime phone number and email address. Ensure these are printed clearly.
If applicable, enter your New York State DMV ID Number. Leave this blank if you do not have one.
Indicate whether you have a CGFNS record. If yes, provide your CGFNS Number.
Fill in the name as it appears on your degree or other credentials, if different from your printed name.
Answer the questions regarding previous applications for licensure, criminal history, and any disciplinary actions. If you answer "Yes" to any questions numbered 10-14, prepare a detailed explanation and include any relevant court records.
List any professional licenses or certificates you currently hold or have held in other states or jurisdictions.
Complete the education section, providing details for all schools attended, including elementary, high school, nursing programs, and postsecondary education. Attach additional sheets if necessary.
Provide information about any licensing examinations you have taken, including the state, profession, exam name, and date.
Complete the child support obligation section, certifying your status regarding child support payments.
Indicate your citizenship or immigration status by checking the appropriate box and providing your alien registration number if applicable.
For RN applicants, check the box that applies to your child abuse identification and reporting coursework requirement.
Check the box that applies to your infection control training requirement.
If applicable, indicate any need for reasonable testing accommodations due to a disability.
Optionally provide your gender and ethnicity for statistical purposes.
Grant permission for the New York State Education Department to release your examination results to your professional school for program review.
Sign and date the affidavit section in the presence of a Notary Public. Ensure the notary completes their section and affixes their stamp.
Mail the completed form along with the $143 fee to the appropriate address provided at the end of the form. If you are submitting an updated Form 1, send it to the designated address without a fee.

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