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Endorsement Online Application

Demographics Step 2 / 15

SSN

Please ensure that your first, Middle/Maiden, and Last Name match fingerprint background check registration.

First Name

Middle Name

Last Name

Maiden Name

Previously Used Names

Suffix

Date of Birth

Gender

Male

Female

The Alabama Board of Nursing must validate your actual home address. Please provide your physical address. Applicants for multistate license are required to submit a completed Primary State of Residence Form along with proof of residency.

Physical Address

Address1

Address2

City

State

County

Zip

Mailing Address

Same as physical address

Address1

Address2

City

State

County

Zip

Contact

Phone #

Alternate Phone

I understand that no one else may complete this application on my behalf and that I am accountable and responsible for the accuracy of any answer or statement on this application and the documents submitted with the application. I affirm that the information on this application and the documents submitted with this application are true and correct. I understand that submission of any false statement or document is grounds for denial, discipline, or revocation of my Alabama license.

Eligibility Criteria Step 3 / 15

If you answer “Yes” to any of the following questions, you are not eligible for a multistate license.You may still be eligible for a single state license.

Do you have a felony conviction?

Yes

Are you currently a participant in any alternative program (a non-disciplinary monitoring program approved by a licensing board)?

Yes

Are any of your nursing licenses, in any jurisdiction, currently under discipline, including revocation, suspension, probation, voluntary surrender, limitation, or other encumbrance?

Yes

Eligibility Criteria Step 4 / 15

If you answer “yes” to any of the following questions, further evaluation will be necessary to determine if you are eligible for a multistate license. If you are deemed ineligible for a multistate license, you may still be eligible for a single state

Have you been found guilty, or entered into an agreed disposition, of a felony offense?

Yes

Have you been convicted or found guilty, or entered into an agreed disposition, of a misdemeanor offense (other than a minor traffic violation)?

Yes

Primary State of Residence Step 5 / 15

Is Alabama your primary state of residence?

Yes

PSOR Step 6 / 15

Name

Date Of Birth

Social Security Number

Address1

Address2

City

State

Zip

AL RN/LPN License #

In order to be issued an Alabama Multistate License you must provide documentation of primary residence in Alabama(ABN Administrative Code 610-x-4 Licensure)

I declare that my current primary state of residence is Alabama. This state is referred to as my home state(ABN Administrative Code 610-x-4.01(15) Licensure)

I am submitting a copy of the following document to prove Alabama residency :

Driver's license with a home address	Voter registration card with a home address
Federal income tax return with a primary state of residence declaration	Military form no. 2058 (state of legal residence certificate)
W2 form from the United States government or any bureau, division, r agency thereof, indicating residence

Proof of residency

I declare Alabama as my primary state of residency effective

I understand that no one else may complete this form on my behalf and that I am accountable and responsible for the accuracy of any answer or statement on this form and the documents submitted with the form. I affirm that the information on this form and the documents submitted with the form are true and correct. I understand that submission of any false statement or document is grounds for denial, discipline, or revocation of my Alabama license.

Signature Of Applicant

Effective Date

Eligibility Criteria Step 8 / 15

Alabama law requires graduation from a nursing program at an institution that is accredited by an organization recognized by the U.S. Department of Education. Please contact your school of nursing if you are unsure of their accreditation before you complete this application.

For practical nurse licensure, have you graduated from an approved practical nursing program in Alabama, or an approved practical nursing program at an accredited institution located in another jurisdiction or territory that substantially meets the same educational criteria as Alabama programs?

Yes

For registered nurse licensure, have you graduated from an approved registered nursing program in Alabama, or an approved registered nursing program at an accredited institution located in another jurisdiction or territory that substantially meet the same educational criteria as Alabama programs?

Yes

Exam Step 9 / 15

Have you ever passed NCLEX or State Boards?

Yes

Education Step 10 / 15

Were you educated in US?

Yes

Program Country

Original Licensure and Other Licensure Step 11 / 15

Original Licensure

State of Licensure

License Number

Other Licensure

Preview Step 13 / 15

E-Signature Step 14 / 15

I affirm that the information recorded on this application concerning any item contained herein is true and correct. I understand that I may be required to submit documentation to support my affirmation. I further understand that any false statement is in violation of the Code of Alabama and the Board of Nursing Administrative Code and constitutes cause for disciplinary action. Your signature is required to complete this application.

I understand that my fingerprint based criminal history report will be submitted through FieldPrint, that my fingerprints will be utilized to conduct a federal and state criminal background check in compliance with Act 2019-102 of the Acts of Alabama, and the results will be considered in determining suitability for licensure.

I have reviewed the Privacy Act Statement.

I have reviewed agency privacy requirements for noncriminal justice applicants.

I understand that applicants with a criminal history record may challenge or appeal any portion of their own Criminal History Record Information (CHRI) that they believe to be incomplete or inaccurate by contacting the Records & Identification Division within Alabama Law Enforcement Agency (ALEA), pursuant to 28 CFR 16.34. Applicants shall have a reasonable amount of time, but not more than thirty (30) days to submit the challenge or appeal.

Electronic Signature

I agree to the terms and conditions mentioned above

Affirm and Submit Step 15 / 15

License Fee

Transaction Fee

Total

Person`s Name on Card

Select Debit or Credit

Card Type

Card#

Expiration Date (MM/YY)

Security Code

5 Digit Billing Zip Code

Note: The Board of Nursing charge, including a convenience fee, will appear on your statement with a description of IGOVSOL*AL Brd Nrsng

State of Licensure

Compact Type

License Number

LPN Single State License by Endorsement	LPN Multistate License by Endorsement
RN Single State License by Endorsement	RN Multistate License by Endorsement