Phn SAMPLE App
Content
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR.
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
Louise R. Bailey, MEd, RN, Executive Officer
APPLICATION FOR PUBLIC HEALTH NURSE (PHN) CERTIFICATION
APPLICATION FEE - $150.00
PERSONAL DATA
LAST NAME:
(PRINT OR TYPE)
Doe
ADDRESS:
FIRST NAME:
MIDDLE NAME:
Jane
Lee
Number and Street
1234 Happy Lane
City
State
Country
Postal/Zip Code
Sacramento
CA
USA
95826
HOME TELEPHONE NUMBER:
ALTERNATE TELEPHONE NUMBER:
E-MAIL ADDRESS:
( 916 ) 555-5555
(
[email protected]
DATE OF BIRTH:
(Month/Day/Year)
11/1/77
)
SOCIAL SECURITY NUMBER or
INDIVIDUAL TAXPAYER
IDENTIFICATION NUMBER:**
PREVIOUS NAMES: (Including Maiden)
MOTHER’S MAIDEN NAME:
(Last Name Only)
Doe
555-55-5555
RN LICENSURE/PUBLIC HEALTH NURSE CERTIFICATION
List ALL States Where You Hold/Held an RN License and
Status:
92929292
California RN License Number: _____________________
2/3/2016
Date Issued: _____________________
California, Current
List ALL States Where You Hold/Held a Public Health Nurse
License/Certificate and Status:
1/31/2018
Expiration Date: _____________________
PUBLIC HEALTH NURSE EDUCATION
TYPE OF PROGRAM:
CERTIFICATE
BACCALAUREATE DEGREE
ENTRY LEVEL MASTERS DEGREE
Leave
MASTERS DEGREE/NURSING
highlighted
portion blank
Entrance Date: __________________
CSUS School of Nursing
___________________________________________________
Name of Public Health Nurse Academic Program
■
Sacramento
CA
USA
___________________________________________________
City
State
Country
Graduation/Completion Date: ___________________
CHILD ABUSE/NEGLECT PREVENTION TRAINING
___________________________________________________
CE Provider/School Name
Number of hours: __________________
Course Name: _______________________________
Leave highlighted
portion blank
Course Number: _______________________________
(Rev 11/15
6
(Questions on both sides of page)
NAME OF APPLICANT:
Jane
Lee
Doe
Student fills this
portion out
BACKGROUND INFORMATION
Have you applied for a Public Health Nurse certificate in California?
If yes:
Name on previous application:
Date Submitted:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Have you ever been issued a Public Health Nurse certificate in California?
If yes: STOP! DO NOT CONTINUE. Please contact the Board regarding whether you should reapply or file a petition
for reinstatement of your California Public Health Nurse certification.
Have you ever had disciplinary proceedings against any license as a RN or any health-care related license or
certificate including revocation, suspension, probation, voluntary surrender, or any other proceeding in any state or
country? If yes, please provide a detailed written explanation, including the date and state or country where the
discipline occurred.
Have you ever been convicted of any offense other than minor traffic violations? If yes, explain fully as described in
the applicant instructions. Convictions must be reported even if they have been adjudicated, dismissed or expunged
or if a diversion program has been completed under the Penal Code or Article 5 of the Vehicle Code. Traffic violations
involving driving under the influence, injury to persons or providing false information must be reported. The definition
of conviction includes a plea of nolo contendere (no contest), as well as pleas or verdicts of guilty. YOU MUST
INCLUDE MISDEMEANOR AS WELL AS FELONY CONVICTIONS.
Have you ever been denied an RN or any other health-care related license in any state/territory? If yes, please
provide a detailed written explanation, including the date and state or country where the discipline occurred.
I understand that I am required to report immediately to the California Board of Registered Nursing if I am convicted of ANY offense that
occurs between the date of this application and the date that a California registered nurse license and/or Public Health Nurse certificate is
issued. I am also required to report to the California Board of Registered Nursing any disciplinary action and/or voluntary surrender against
ANY health-care related license/certificate that occurs between the date of this application and the date that a California registered nurse
license and/or Public Health Nurse certificate is issued. I understand that failure to do so may result in denial of this application or
subsequent disciplinary action against my license/certificate.
I certify under penalty of perjury under the laws of the State of California, that all
information provided in connection with this online application for license/certification is
true, correct and complete. Providing false information or omitting required information
is grounds for denial of licensure/certification or license/certificate revocation in
California. I have read and understand the disclosure statements provided in the
instructions for this application. I hereby grant the Department of Consumer Affairs
entity permission to verify any information contained in this application.
_____________________________________________
SIGNATURE OF APPLICANT
Attach a recent 2”x2”
passport type photograph.
Please tape on all four sides.
Head and shoulders only
________________
DATE
** SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER DISCLOSURE STATEMENT
Disclosure of your social security number or individual taxpayer identification number is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USCA (c)(2)(C)
authorizes collection of your social security number or individual taxpayer identification number. Your social security number or individual taxpayer identification number will be used exclusively for tax
enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with section 17520 of the Family Code, or for verification of licensure or examination
status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security number or individual
taxpayer identification number, your application for initial or renewal license will not be processed and you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you.
(Rev 11/15)
7
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR.
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
Louise R. Bailey, MEd, RN, Executive Officer
REQUEST FOR TRANSCRIPT
PUBLIC HEALTH NURSE CERTIFICATION
A. TO BE COMPLETED BY APPLICANT
Send this form to your baccalaureate, entry-level masters or master’s school of nursing. If you need to contact more than one school,
this form may be reproduced. Transcripts must include all completed course work and reflect the degree awarded and date conferred.
An official transcript must come directly from the school of nursing to the Board of Registered Nursing. Transcripts are not accepted
from applicants.
NAME:
Last
First
Doe
Middle
Jane
Previous Names (Including Maiden):
Lee
ADDRESS: Street
City
1234 Happy Lane
Sacramento CA
SOCIAL SECURITY NUMBER or
INDIVIDUAL TAXPAYER
IDENTIFICATION NUMBER:
State
Zip Code
BIRTHDATE:
TELEPHONE NUMBER:
Home: ( 916 ) 555-5555
Work: (
)
11/1/77
Month
555-55-5555
Day
95826
Year
NAME OF BSN/ELM/MSN NURSING SCHOOL:
YEARS ATTENDED:
California State University, Sacramento
2014 to __________
2016
__________
YEAR GRADUATED:
LOCATION:
City
State
Sacramento,
(Country)
CA
USA
2016
SIGNATURE OF APPLICANT: ______________________________________________ DATE: ______________________
B. TO BE COMPLETED BY THE SCHOOL OF NURSING
The above applicant has applied for Public Health Nurse Certification in California. Please supply the following
information and attach an official transcript.
ENTRANCE DATE:
DATE DEGREE AWARDED:
Leave Blank
TYPE OF DEGREE AWARDED:
Leave Blank
Leave Blank
OUT-OF-STATE GRADUATES ONLY
Is this school NLN accredited?
Yes
No
If yes, when:
Is this school CCNE accredited?
Yes
No
If yes, when:
Was the school accredited at the time of applicant’s graduation?
Yes
No
SIGNATURE OF SCHOOL
OFFICIAL:
TELEPHONE:
NAME & TITLE:
DATE:
8
(
)
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
Louise R. Bailey, MEd, RN, Executive Officer
APPLICATION FOR PUBLIC HEALTH NURSE (PHN) CERTIFICATION
APPLICATION FEE - $150.00
PERSONAL DATA
LAST NAME:
(PRINT OR TYPE)
Doe
ADDRESS:
FIRST NAME:
MIDDLE NAME:
Jane
Lee
Number and Street
1234 Happy Lane
City
State
Country
Postal/Zip Code
Sacramento
CA
USA
95826
HOME TELEPHONE NUMBER:
ALTERNATE TELEPHONE NUMBER:
E-MAIL ADDRESS:
( 916 ) 555-5555
(
[email protected]
DATE OF BIRTH:
(Month/Day/Year)
11/1/77
)
SOCIAL SECURITY NUMBER or
INDIVIDUAL TAXPAYER
IDENTIFICATION NUMBER:**
PREVIOUS NAMES: (Including Maiden)
MOTHER’S MAIDEN NAME:
(Last Name Only)
Doe
555-55-5555
RN LICENSURE/PUBLIC HEALTH NURSE CERTIFICATION
List ALL States Where You Hold/Held an RN License and
Status:
92929292
California RN License Number: _____________________
2/3/2016
Date Issued: _____________________
California, Current
List ALL States Where You Hold/Held a Public Health Nurse
License/Certificate and Status:
1/31/2018
Expiration Date: _____________________
PUBLIC HEALTH NURSE EDUCATION
TYPE OF PROGRAM:
CERTIFICATE
BACCALAUREATE DEGREE
ENTRY LEVEL MASTERS DEGREE
Leave
MASTERS DEGREE/NURSING
highlighted
portion blank
Entrance Date: __________________
CSUS School of Nursing
___________________________________________________
Name of Public Health Nurse Academic Program
■
Sacramento
CA
USA
___________________________________________________
City
State
Country
Graduation/Completion Date: ___________________
CHILD ABUSE/NEGLECT PREVENTION TRAINING
___________________________________________________
CE Provider/School Name
Number of hours: __________________
Course Name: _______________________________
Leave highlighted
portion blank
Course Number: _______________________________
(Rev 11/15
6
(Questions on both sides of page)
NAME OF APPLICANT:
Jane
Lee
Doe
Student fills this
portion out
BACKGROUND INFORMATION
Have you applied for a Public Health Nurse certificate in California?
If yes:
Name on previous application:
Date Submitted:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Have you ever been issued a Public Health Nurse certificate in California?
If yes: STOP! DO NOT CONTINUE. Please contact the Board regarding whether you should reapply or file a petition
for reinstatement of your California Public Health Nurse certification.
Have you ever had disciplinary proceedings against any license as a RN or any health-care related license or
certificate including revocation, suspension, probation, voluntary surrender, or any other proceeding in any state or
country? If yes, please provide a detailed written explanation, including the date and state or country where the
discipline occurred.
Have you ever been convicted of any offense other than minor traffic violations? If yes, explain fully as described in
the applicant instructions. Convictions must be reported even if they have been adjudicated, dismissed or expunged
or if a diversion program has been completed under the Penal Code or Article 5 of the Vehicle Code. Traffic violations
involving driving under the influence, injury to persons or providing false information must be reported. The definition
of conviction includes a plea of nolo contendere (no contest), as well as pleas or verdicts of guilty. YOU MUST
INCLUDE MISDEMEANOR AS WELL AS FELONY CONVICTIONS.
Have you ever been denied an RN or any other health-care related license in any state/territory? If yes, please
provide a detailed written explanation, including the date and state or country where the discipline occurred.
I understand that I am required to report immediately to the California Board of Registered Nursing if I am convicted of ANY offense that
occurs between the date of this application and the date that a California registered nurse license and/or Public Health Nurse certificate is
issued. I am also required to report to the California Board of Registered Nursing any disciplinary action and/or voluntary surrender against
ANY health-care related license/certificate that occurs between the date of this application and the date that a California registered nurse
license and/or Public Health Nurse certificate is issued. I understand that failure to do so may result in denial of this application or
subsequent disciplinary action against my license/certificate.
I certify under penalty of perjury under the laws of the State of California, that all
information provided in connection with this online application for license/certification is
true, correct and complete. Providing false information or omitting required information
is grounds for denial of licensure/certification or license/certificate revocation in
California. I have read and understand the disclosure statements provided in the
instructions for this application. I hereby grant the Department of Consumer Affairs
entity permission to verify any information contained in this application.
_____________________________________________
SIGNATURE OF APPLICANT
Attach a recent 2”x2”
passport type photograph.
Please tape on all four sides.
Head and shoulders only
________________
DATE
** SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER DISCLOSURE STATEMENT
Disclosure of your social security number or individual taxpayer identification number is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USCA (c)(2)(C)
authorizes collection of your social security number or individual taxpayer identification number. Your social security number or individual taxpayer identification number will be used exclusively for tax
enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with section 17520 of the Family Code, or for verification of licensure or examination
status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security number or individual
taxpayer identification number, your application for initial or renewal license will not be processed and you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you.
(Rev 11/15)
7
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR.
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
Louise R. Bailey, MEd, RN, Executive Officer
REQUEST FOR TRANSCRIPT
PUBLIC HEALTH NURSE CERTIFICATION
A. TO BE COMPLETED BY APPLICANT
Send this form to your baccalaureate, entry-level masters or master’s school of nursing. If you need to contact more than one school,
this form may be reproduced. Transcripts must include all completed course work and reflect the degree awarded and date conferred.
An official transcript must come directly from the school of nursing to the Board of Registered Nursing. Transcripts are not accepted
from applicants.
NAME:
Last
First
Doe
Middle
Jane
Previous Names (Including Maiden):
Lee
ADDRESS: Street
City
1234 Happy Lane
Sacramento CA
SOCIAL SECURITY NUMBER or
INDIVIDUAL TAXPAYER
IDENTIFICATION NUMBER:
State
Zip Code
BIRTHDATE:
TELEPHONE NUMBER:
Home: ( 916 ) 555-5555
Work: (
)
11/1/77
Month
555-55-5555
Day
95826
Year
NAME OF BSN/ELM/MSN NURSING SCHOOL:
YEARS ATTENDED:
California State University, Sacramento
2014 to __________
2016
__________
YEAR GRADUATED:
LOCATION:
City
State
Sacramento,
(Country)
CA
USA
2016
SIGNATURE OF APPLICANT: ______________________________________________ DATE: ______________________
B. TO BE COMPLETED BY THE SCHOOL OF NURSING
The above applicant has applied for Public Health Nurse Certification in California. Please supply the following
information and attach an official transcript.
ENTRANCE DATE:
DATE DEGREE AWARDED:
Leave Blank
TYPE OF DEGREE AWARDED:
Leave Blank
Leave Blank
OUT-OF-STATE GRADUATES ONLY
Is this school NLN accredited?
Yes
No
If yes, when:
Is this school CCNE accredited?
Yes
No
If yes, when:
Was the school accredited at the time of applicant’s graduation?
Yes
No
SIGNATURE OF SCHOOL
OFFICIAL:
TELEPHONE:
NAME & TITLE:
DATE:
8
(
)
