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Unformatted text preview: RN Renewal 2011 0131 - March 2011 1 Registered Nurse Renewal Application Current Expiration 3/31/2011 Renewal Period Covering 4/1/2011 3/31/2013 Renewal Application Fee $95.00 Non-Refundable Processing Fee You Must Complete The Information Below: License Number: Circle One: Mr. Mrs. Ms. For Office Use Only Directions : To renew you must enclose a check in the amount indicated, payable in US funds from a bank with a United States affiliate to Office of the Secretary of State. The renewal application fee is non-refundable. If the completed renewal, along with all supporting documentation, is not received 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. (Circle One) Has your name changed since you last renewed, or if this is your first renewal since you were originally licensed? If Yes, you must attach a copy of your marriage license, civil union license or section of divorce decree granting you the authority to change your name. Yes No Section A: Demographic Information P.O. Box Street/Apt # City/State/Zip If your mailing address has changed , indicate your new address in the box to the right. Note: It is unprofessional conduct for a licensee to fail to notify the Secretary of States Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14). Country P.O. Box Street/Apt # If your 911 address has changed , indicate your new address in the box to the right. City/State/Zip Date of Birth Place of Birth (City, State, Country) Gender (Circle One) 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, Child Support, and the Department of Labor 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) Vermont Secretary of State Office of Professional Regulation National Life Building, North FL 2 Montpelier VT 05620-3402 Vermont Board of Nursing (802) 828-2396 Renewal Clerk (802) 828-1505 www.vtprofessionals.org Phone: ( ) - Cell Phone: ( ) - Fax: ( ) - E-Mail Address: Name: __________________________________ License #: ______________________ 2 RN Renewal 2011 0131 - March 2011 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) Child Support Orders (15 V....
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- Spring '11