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Board of Nursing - Vermont Secretary of State - Office of Professional Regulatio nNational Life Building, North, Floor 2, Montpelier, VT 05620-3402E-Mail:foreign _nurse@sec.state.vt.usWeb:www.vtprofessionals.org 5 Verification of Education Attach Stamped Official Transcript and Clinical TranscriptsThis page and the following page mus t also be stamped by the school Applicant: Complete the box below and have the School of Nursing complete this p age and the page following. Last Name First Name MI Former/Maiden Name ( As on Application AND Passport ) ( On School Documents )Mailing Address Street City State Zip Date of BirthI hereby authorize the School of Nursing to furnish to the Board of Nursing the information requestedbelow. Signature Date Information Below To Be Completed by the School of Nursing: (Attach Official Tra nscript and Detailed CourseDescriptions) Name of NursingSchoolMailingAddressProgram Commenced (mm/dd/yyyy) Date of Gradua tion (mm/dd/yyyy) Degree/Certificate EarnedSummary of Theoretical Education and Clinical Practice Hours Was the language of instruction and textbooks for the nurse s program inENGLISH? YES NO Clinical Area ofPracticeTheoryHoursCourseTitle/Number(REQUIRED)ClinicalHoursCour seTitle/Number(REQUIRED) Care of the Adult-Medical NursingCare of the Adult-SurgicalNursingMaternal/Infan t NursingPsychiatric/Mental HealthNursingPediatric Nursing/Care ofthe Sick Child :

Board of Nursing - Vermont Secretary of State - Office of Professional Regulatio nNational Life Building, North, Floor 2, Montpelier, VT 05620-3402E-Mail:foreign _nurse@sec.state.vt.usWeb:www.vtprofessionals.org 6 Support Courses:TheoryHoursCourseTitle/Number(REQUIRED)ClinicalHoursCourseTitle/ Number(REQUIRED) Anatomy and PhysiologyMicrobiologyPsychologyPrint Name DateTelephonePosition/Tit leEmailSignature ofDean/DirectorOfficial SchoolSeal/Stamp Further Information: If the course titles do not match the subjects as theyare l isted on this form (in the specific language we use) it is very importantthat yo u fill out the columns showing us in which courses (or modules) thetheory and cl inical experience for each subject was taught and for howmany hours of in each c ourse. We cannot approve an applicant without thisinformation.Note: Please sign

and place official school stamp on BOTH pages of thisform. Thank you. Board of Nursing - Vermont Secretary of State - Office of Professional Regulatio nNational Life Building, North, Floor 2, Montpelier, VT 05620-3402E-Mail:foreign _nurse@sec.state.vt.usWeb:www.vtprofessionals.org 7 Verification of Licensure- To Be Filled Out By Nursing Regulatory Body Last Name: First Name: Middle Initial:Country of Licensure: License Number:Licen se Issue Date: License Expiry Date: Is this License considered to be In Good Standing? (please circle) YES NO If no, what is its current status (valid, expired, revoked, suspended, or condit ioned)? Are there any conditions thatapply to the license and what are they? Ple ase comment below. Use additional pages if necessary.Certifying/Regulatory Body Name:Individual Name:Date:Place seal/stamp ofCertification here.This form should be sealed in an envelope by the regulating body and returned to the license hol der.9-11-08 lcp NCLEX Application Vermont Download this Document for FreePrintMobileCollectionsReport Document This is a private document. Info and Rating Follow KAKKAMPI Share & Embed Related Documents PreviousNext 13 p. 14 p. 5 p. 9 p. 9 p. 9 p. 9 p. 9 p. 9 p. 9 p. 9 p. 9 p. 9 p. 9 p. 9 p. 9 p. 6 p. 6 p. 7 p. 6 p. 132 p. 1 p. 1 p. 1 p. 2 p. 12 p. 1 p. 27 p. 4 p.

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Add a Comment Submit Characters: 400 Lea Cayanan Encinaleft a comment Hi is it required to hve a CGFNS CERTIFICATE before taking up NCLEX In Vermont? thanks.or is it possible to tke the NCLEX only without CGFNS 02 / 14 / 2012

Reply Shirlee_Sarigu_9919left a comment how to print the downloaded forms at scribd? i already paid?why there are markin gs on the forms that is not found on the original ones.. 10 / 13 / 2010 Reply This document has made it onto the Rising list! 08 / 26 / 2010 Upload a Document Search Documents Follow Us!scribd.com/scribdtwitter.com/scribd facebook.com/scribd AboutPressBlogPartnersScribd 101Web StuffSupportFAQDevelopers / APIJobsTermsCopy rightPrivacy Copyright 2012 Scribd Inc.Language:English