The Vermont Nurse Renewal form is a crucial document that registered nurses in Vermont must complete to renew their licenses. This form ensures that nurses maintain their credentials and comply with state regulations, allowing them to continue practicing legally. If you're ready to renew your license, please fill out the form by clicking the button below.
The Vermont Nurse Renewal form is a crucial document for registered nurses seeking to maintain their licensure in the state. This form must be completed and submitted to the Vermont Secretary of State's Office of Professional Regulation, along with a non-refundable renewal application fee of $95. Nurses should be aware of the renewal period, which typically spans from April 1 to March 31 of the following two years. Timely submission is essential, as late applications incur penalties that escalate the longer they are delayed. The form requires personal information, including name, address, and Social Security number, which is necessary for compliance with state regulations. Additionally, applicants must affirm their good standing regarding child support, tax compliance, and any unpaid judgments. The form also includes sections that assess the applicant’s fitness to practice, requiring disclosures about any disciplinary actions or criminal convictions. Furthermore, nurses must document their practice hours to ensure they meet the required experience criteria. This comprehensive renewal process not only safeguards the integrity of the nursing profession but also upholds the standards of care for patients across Vermont.
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Vermont Secretary of State
Attn: Renewal Clerk
Office of Professional Regulation
89Main St. 3rd Floor Montpelier, VT 05620-3420
Board of Nursing
Renewal Clerk
(802)828-1505
www.vtprofessionals.org
Registered Nurse Renewal Application
Current Expiration
Renewal Period Covering
Renewal Application Fee
03/31/2013
04/01/2013 through 03/31/2015
$95.00 [Non–Refundable Processing Fee]
Checks Payable to: Vermont Secretary of State
You Must Complete The Information Below:
For Office Use Only
License #: __________ ----_______________________________
Name: _________________________________________________
Address: _______________________________________________
City/State/ZIP: ___________________________________________
Country: _______________________________________________
Directions: To renew you must enclose a check or money order in the amount indicated, payable in US funds from a bank with a United States affiliate to “Vermont Secretary of State.” The renewal application fee is non-refundable. If the completed renewal, along with all supporting documentation, is not received in the Office by the expiration date you will be required to pay a late renewal penalty. The penalty is $25.00 for renewals submitted less than 30 days late. Thereafter, the penalty increases by $5.00 for every additional month or fraction of a month, not to exceed $100.00.
Reminder: You may not practice your licensed profession without an active license. Faxes not accepted.
Has your name changed since you last renewed, or were originally licensed?
(Circle One)
If “Yes,” you must attach a copy of your marriage license, civil union license or section of divorce decree
Yes
No
granting you the authority to change your name.
Section A: Demographic Information
If your mailing address has changed,
P.O. Box
indicate your new address in the box to the
right.
Street/Apt #
Note: It is unprofessional conduct for a
City/State/Zip
licensee to fail to notify the Secretary of State’s
Office of a change of name or address within
Country
thirty (30) days (3 V.S.A. §129a(a)(14)).
If your 911 address has changed,
indicate your new address in the box to the right.
Suite/Department/Floor
Phone: (
)
-
Cell Phone: (
E-Mail Address:
Date of Birth
Place of Birth (City, State, Country)
Gender
Female
Male
Social Security Number: ________/_______/__________** (Providing your social security number (SSN) is mandatory, and requested
under the authority granted by 42 U.S.C. §405(c)(2)(C). It will be used by the Departments of Taxes, and Child Support in the administration of Vermont law, to identify individuals affected by such laws. Your SSN is not disclosed as part of a public records request);
-OR-
Passport Number: _________________________*** (If you do not have a social security number you must provide a passport number as
evidence that there is no attempt to procure a license fraudulently (3 V.S.A. §129a)
Section B: Vermont Mandatory “Good Standing” Declarations
CHILD SUPPORT:
Child Support Orders (15 V.S.A. §795(c)): As of the date of this application: (you must check one)
Not Applicable – I am not subject to a child support order
I am in good standing*
I am in compliance with a payment plan approved by the Office of Child Support
I am NOT in good standing*
TAXES:
Tax Compliance (32 V.S.A. §3113(b)): As of the date of this application: (you must check one)
Not Applicable – I have never lived or worked in Vermont and do not owe Vermont taxes
I am in compliance with a payment plan approved by the Vermont Department of Taxes
DISTRICT COURT FINES / JUDICIAL BUREAU:
Unpaid Judgments (4 V.S.A. §1110(b and c)): As of the date of this application: (you must check one)
Not Applicable – I do not have any unpaid judgments
I am in good standing* with the judicial bureau or district court for fines or penalties for a violation or criminal offense
I am NOT in good standing.*
*“Good standing” is defined in the statutes cited above. For more information, refer to the relevant statute specific to the particular question.
Name (print): ___________________________________
License Number: ___________________________
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Section C:
Vermont Mandatory Credential and Fitness Questions
Please circle Yes or No for each of these questions. If the answer is “Yes,” follow the provided instructions.
Since you were originally licensed or since you completed your last renewal application:
Have you committed acts of abuse, neglect, or misappropriation of patient property?
If “Yes,” provide a detailed written explanation and attach all related documents.
Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) denied an
application by you for a license, certificate, or registration to practice a profession or occupation?
If “Yes,” you must attach a copy of the order or official notification of the action(s).
Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) restricted,
suspended, revoked, or taken any other disciplinary action against a license, certificate, or registration
that you hold or held in any profession or occupation?
If “Yes,” you must provide a copy of the order or official notification of the action.
Have you ever surrendered a license, certificate, or registration to a licensing authority?
If “Yes,” you must provide a detailed written explanation.
Are you currently under investigation by a licensing authority?
If “Yes,” you must provide a detailed written explanation and a copy of any available information from the
licensing authority.
Have you been convicted of a crime other than a minor traffic violation? (Note: Driving While Intoxicated
and Driving Under the Influence are not “minor traffic violations.”)
If “Yes,” you must provide a detailed written explanation and attach the official court documents.
Do you have any criminal charges pending against you in any jurisdiction (US or elsewhere)?
If “Yes,” you must provide a detailed written explanation and attach a copy of the charging documents.
Note: Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. §129a(a)(11).
The answers to the following questions are not subject to public disclosure
Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to
practice this profession with reasonable skill and safety?
If “Yes,” you must have your health care provider submit a detailed statement explaining how you are
able to practice safely.
Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice
this profession with reasonable skill and safety?
Are you currently addicted to or in any way dependent on alcohol or habit forming drugs?
Are you currently participating in a supervised program or professional assistance program which
monitors you in order to assure that you are not engaging in the use of alcohol or controlled substances?
If “Yes,” please provide the contract/stipulation under which you are practicing.
3
Section D: RN Nursing Education and Practice Requirements
Board of Nursing Administrative Rules, Part 9 Education and Practice Requirements, Rule 9.1 (b) and(c)
Practice of nursing at the level of licensure within the past five years means practice as described in 26 V.S.A. § 1572, definitions, for at least 120 days, 960 hours, in the five years prior to the expiration date or 50 days, 400 hours, within the two years prior to the expiration date. Eight hours are equivalent to one day of nursing practice.
Program and Practice Experience Requirement
(Check the box that applies to your license.)
I have completed my original/initial Nursing program or a Re-entry program within the last five (5) years; therefore I do not have to meet the practice experience requirement (4/1/2008 – 3/31/2013).
I have practiced as a Registered Nurse for 50 days (400 hours) within the last two (2) years OR 120 days (960 hours) within the last 5 years.
I have NOT met the program or practice experience requirement
(You must contact the Board office at 802-828-2396)
Section E: Audit Information
The Office of Professional Regulation reserves the right to verify information submitted by licensees for renewal through a random employment audit. You must retain all names and complete dates of employment for the five years prior to this renewal application. To assist you in documenting your practice hours, please download the “RN Practice History Record” form from our website at www.vtprofessionals.org/opr1/nurses.
If you are selected for an audit, a form will be sent to you requiring the names and addresses of all employment for the past five years which you have used to satisfy your practice hour requirements and you will have to report the name and title of your nursing supervisor.
For Private Duty you will need the following:
1.An Official letter from the client/patient’s attending Physician or Advanced Practice Registered Nurse (APRN) on their letterhead, stating that RN care was required. The letter must clearly list the Physician or APRN name, title, contact telephone number and have their signature.
2.A letter from your Employer or Client, verifying your role and duties as a Private Duty Nurse. They must verify the number of days, hours and dates worked. The letter must clearly list the Employer/Clients name, contact telephone number, email address, mailing address and have their signature.
For Volunteer Duty you will need the following:
An Official letter from your Employer sent directly to the Vermont Board of Nursing office from the Director of Nursing or Director of Human Resources. A copy of your Job Description as a Volunteer Nurse, and a letter listing the number of days, hours and dates worked. The letter must clearly list the name of the Director of Nursing or Director of Human Resources, their telephone number, email address, mailing address and have their signature.
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Section F:
Late Renewals
If you are renewing more than 30 days late, you must submit a completed renewal application and the “RN Practice History Record” (Go to www.vtprofessionals.org), select Nursing from the drop down list of professions located on the left side, under License Information and Forms, click RN-Registered Nurse, under Application Forms click RN Practice History Record).
If you met the practice requirement via Private Duty or Volunteer and are renewing more than 30 days late, you must submit a completed renewal application, the “RN Practice History Record” and the requirements noted in Section E.
If this is a late renewal, have you been practicing in Vermont since your license expired?
If “Yes,” please attach a description of the extent of your practice since your license expired.
N/A
Section G: Affirmation
Statement of Applicant
I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for renewal or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. §2901)
Signature of Applicant **(REQUIRED)**
Signature Date (MM/DD/YYYY)
Print Name:
License #
______________________________
_
_ ----____________________________
5
89 Main St. 3rd Floor
Montpelier, VT 05620-3420
Phone: (802) 828-1505 Fax: (802) 828-2465
Vermont Office of Professional Regulation Survey (optional)
2013 Renewal
Name: _______________________________________________
1.Would you be willing to serve as a Board/Advisor member of the Board/Commission/Advisory panel for your profession?
If you answer "Yes," submit a letter of intent and resume to the Office for consideration.
2.Would you be willing to serve as an Ad Hoc member of the Board/Commission/Advisory panel for your profession?
3.Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession?
If you answered “Yes” to the question above, what is your area of expertise?
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The Vermont Nurse Renewal form shares similarities with the California Nurse License Renewal Application. Both documents require applicants to provide personal information, including name, address, and license number. They also mandate the payment of a non-refundable renewal fee. Each form includes sections dedicated to confirming compliance with state regulations, such as child support and tax obligations. Additionally, both applications inquire about any disciplinary actions or criminal convictions that may affect the applicant's licensure status.
Another comparable document is the New York State Nurse License Renewal Application. This form, like the Vermont version, requires demographic information and a declaration of good standing with child support and tax obligations. Both documents emphasize the importance of maintaining an active license for legal practice. Furthermore, applicants must attest to their professional conduct and disclose any disciplinary actions or legal issues that may impact their nursing practice.
The Texas Nurse License Renewal Application is also similar to the Vermont Nurse Renewal form. It requires applicants to submit personal information and pay a renewal fee. Both forms include sections that assess the applicant's compliance with state laws, including child support and tax status. Additionally, they require disclosure of any criminal history or disciplinary actions, ensuring that nurses maintain the integrity of their profession.
The Florida Nurse License Renewal Application mirrors the Vermont form in several ways. Both documents collect essential personal information and require a renewal fee. They also include sections that address good standing with child support and tax obligations. Additionally, both forms ask about any disciplinary actions or criminal convictions, emphasizing the importance of transparency in maintaining nursing licenses.
The Illinois Nurse License Renewal Application is another document that resembles the Vermont Nurse Renewal form. It gathers similar demographic information and requires a renewal fee. Both applications include mandatory sections that assess the applicant's compliance with child support and tax laws. Furthermore, they require applicants to disclose any past disciplinary actions or legal issues that could affect their nursing license.
The Ohio Nurse License Renewal Application is comparable to the Vermont Nurse Renewal form as well. It requires the submission of personal information and payment of a non-refundable fee. Both forms include sections that confirm compliance with state regulations regarding child support and taxes. Additionally, they inquire about any disciplinary actions or criminal convictions, ensuring that applicants maintain professional standards.
The Pennsylvania Nurse License Renewal Application shares similarities with the Vermont form. Both documents require personal information and a renewal fee. They also include sections addressing good standing with child support and tax obligations. Furthermore, both applications require disclosure of any disciplinary actions or criminal history, reinforcing the importance of ethical practice in nursing.
The Massachusetts Nurse License Renewal Application is similar to the Vermont Nurse Renewal form in that it requires personal information and a renewal fee. Both forms emphasize compliance with child support and tax regulations. They also ask about any disciplinary actions or criminal convictions that may impact the applicant's ability to practice nursing legally.
For job seekers looking for a streamlined process, the comprehensive Employment Application Pdf form is an essential tool that consolidates personal information, work history, and qualifications into a standardized format, aiding both applicants and employers in the hiring process.
Finally, the Georgia Nurse License Renewal Application resembles the Vermont Nurse Renewal form. It requires applicants to provide personal information and pay a renewal fee. Both documents include sections that assess compliance with child support and tax obligations. Additionally, they require disclosure of any past disciplinary actions or legal issues, ensuring that nurses uphold the standards of their profession.
This is incorrect. The Vermont Nurse Renewal form must be mailed. Fax submissions are not accepted, so ensure you send your application through the postal service.
The renewal application fee of $95.00 is non-refundable. Once you submit your payment, it cannot be returned, regardless of the outcome of your application.
Practicing nursing without an active license is prohibited. Ensure your renewal application is submitted on time to avoid any lapse in your license.
If your name has changed, you must attach documentation, such as a marriage license or divorce decree, to your renewal application. Failing to report a name change can be considered unprofessional conduct.
This is false. Certain documents are required to complete your application, especially if there have been changes in your personal circumstances, such as legal issues or name changes.
Providing your Social Security Number is mandatory unless you do not possess one. In that case, a passport number must be submitted to verify your identity.
Every renewal application requires the completion of the demographic information section. This ensures that your records are current and accurate.
Late renewal penalties increase over time. If your application is submitted less than 30 days late, the penalty is $25.00. After that, it increases by $5.00 for each additional month, up to a maximum of $100.00.
Documentation proving your practice hours is essential. If selected for an audit, you will need to provide evidence of your nursing practice to meet the requirements.