The Vermont Nurse Renewal form is a crucial document for registered nurses seeking to maintain their licensure in the state of Vermont. This form requires detailed personal and professional information, including demographic data and compliance with state regulations. To ensure uninterrupted practice, complete the renewal form accurately and submit it before the expiration date by clicking the button below.
The Vermont Nurse Renewal form is an essential document for registered nurses looking to maintain their active licensure in the state. It encompasses several critical components that ensure compliance with state regulations and professional standards. At its core, the form requires nurses to provide personal information, including their name, address, and contact details, as well as their license number. A non-refundable renewal fee of $95 must accompany the application, which underscores the importance of timely submission. Nurses must also declare their compliance with child support and tax obligations, confirming their good standing in these areas. Additionally, the form includes a series of questions regarding the applicant's professional conduct, such as any past disciplinary actions or criminal convictions, ensuring that only qualified individuals continue to practice. The application process also emphasizes the necessity of meeting specific practice requirements, mandating a minimum number of practice hours within the preceding years. For those renewing late, additional documentation and fees may apply. Ultimately, this renewal form is not just a bureaucratic hurdle; it is a vital tool for safeguarding public health by ensuring that all practicing nurses meet the necessary standards of care.
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.
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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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