important – please read carefully before submitting …

IMPORTANT – PLEASE READ CAREFULLY BEFORE SUBMITTING YOUR APPLICATION FOR

LPN, RN OR APRN LICENSE In addition to the requirements attached to the application for a Hawaii nurse license by exam or endorsement, the following are also required to apply for a Hawaii LPN or RN or APRN license whether you are applying by exam, endorsement or for APRN.

Applications will not be processed or be delayed if:

An older version of the application is submitted; Incomplete applications, not responding to all questions or failing to provide required

signed statement/explanation and court documents or Board orders for any if you answered “yes” to the prior conviction or prior disciplinary action question or not responding to the question truthfully;

Filing incorrect application; or Failure to submit required documents as applicable, i.e. copy of government photo I.D.,

social security card.

Licensed Practical Nurse or Registered Nurse – Exam Applicants

• CURRENT APPLICATION

We will only accept the most current revised applications that are posted online. No "old" applications will be accepted. Submitting an outdated application will delay processing.

• GOVERNMENT ISSUED IDENTIFICATION AND SOCIAL SECURITY CARD

Additional documentation required to be filed with application:

Legible copy of government issued photo ID that includes your date of birth (same photo ID to be used for entry into the exam); and

Legible copy of your “signed” social security card.

• CRIMINAL HISTORY RECORD CHECK

All applicants for a Hawaii nurse license are required to be fingerprinted for a criminal history record check.

Any application received after July 1, 2017 or license issued on or after July 1, 2017 are required to be fingerprinted.

CRIMINAL HISTORY RECORD CHECK LICENSE REQUIREMENT

REQUIREMENTS AND INSTRUCTIONS

REQUIREMENTS:

• Any licensed issued on or after July 1, 2017 or if you are applying for restoration or reactivating your Hawaii nurse license (LPN, RN, APRN or Prescriptive authority)

• You will be required to comply with the electronic fingerprinting requirements for the purpose of obtaining federal (FBI national criminal history check) and the State of Hawaii (Hawaii Criminal Justice Data Center) criminal history record checks in accordance with section 847-2.7.

• ELECTRONIC FINGERPRINTING

INSTRUCTIONS:

• Please visit Fieldprint Inc., at: http://fieldprinthawaii.com to make an appointment or to inquire about other available site locations on the Continental United States, or call (877) 614-4361;

•• Fieldprint code that you must enter

is FPHIBrdNursing (not case sensitive);

•

• The applicant shall bear the cost of the fingerprint processing and all fingerprinting fees shall be paid directly to Fieldprint; and

•

• You must file your license application within thirty (30) days of the fingerprinting to ensure that the results can be obtained.

•

• If we are unable to obtain the results, you will be required to submit to the fingerprinting process again.

NOTE:

• If you were previously fingerprinted by another board of nursing or employer, you still have to submit to the electronic fingerprinting for a Hawaii nurse license. The Fieldprint code is specifically for Hawaii nurse licensees and applicants.

• If you do not use this code, FPHIBrdNursing (not case sensitive), we will not

be able to retrieve your report and you will have to go back to get fingerprinted and pay another fee.

Applicants who are not in the U.S. or in a location that Fieldprint is unable to service will have to wait until you enter the U.S. and be fingerprinted. Please be advised that a license to practice will not be issued until the fingerprint requirement(s) are met.

• TRANSCRIPTS

Exam applicants and applicants for APRN license must have your transcripts requested and sent directly from your nursing program. We will NOT accept transcripts unless they are in a sealed envelope from your nursing program.

If you were educated outside the U.S., you must have your education reviewed by a Board-approved credentialing organization.

Currently there are two (2) credentialing organizations approved by the Board:

CGFNS Josef Silny & Associates, Inc., International Education Consultants

You shall make arrangements to have one of the credentialing organizations prepare a credentials review to determine if your education is comparable to a graduate of a U.S. accredited nursing program at the time of graduation.

The credentials evaluation must either be retrievable online directly from the credentialing organization or directly emailed to us from the credentialing organization. Copies will NOT be accepted.

The credentials evaluation must indicate that your education is comparable to a graduate of a U.S. accredited nursing program without any deficiencies or your application will be deferred.

• AUTHORIZATION TO WORK IN THE U.S. AND SOCIAL SECURITY NUMBER/CARD

If you are not authorized to work in the U.S. and do not have a U.S. social security number issued to you, you may still apply to sit for the NCLEX, however, upon passing, you may be issued a conditional approval.

This conditional approval is NOT a license to practice nursing. Once you enter the U.S., you will be required to complete your fingerprinting and once you can provide proof of your authorization to work in the U.S. and a signed social security card, a nurse license may be issued.

When submitting your application, should you answer “No” to the question “Are you a U.S. citizen, a U.S. national, or an alien authorized to work in the United States?, you may submit a signed statement clarifying that you currently reside outside the U.S. and is currently not authorized to work in the U.S. nor do you have a U.S. social security card/number and understand that upon approval and passing the exam you may be issued a conditional approval until you provide official documentation that you are authorized to work in the U.S. and your social security card. This statement will assist in processing your application more efficiently as we will not assume that you responded to this question in error.

• FAILING THE NCLEX

If you have failed the NCLEX PN or NCLEX RN three (3) times, regardless of which state or jurisdiction you were made eligible (If you were previously approved to sit for the NCLEX in another state and failed the exam, those failed attempts will count towards the 3 times.), you will be required to complete a board approved remedial course before being approved to sit for the NCLEX pursuant to the following administrative rules:

§16-89-9 Examination policies. (a) The passing standards for the NCLEX-RN and NCLEX-PN examinations accurately reflect the amount of nursing ability currently required to practice competently at the entry level. The passing standards for the NCLEX-RN and the NCLEX-PN shall be established by the National Council of State Boards of Nursing unless otherwise determined by the board.

(b) Candidates may take the examination, provided candidates register for each examination. Any candidate who fails the license examination three times, regardless of when or where the examination was taken, and regardless of which state or jurisdiction the candidate was made eligible, shall be required to complete a board-approved remedial course and submit proof of passing the course before the candidate may be approved for reexamination. The candidate shall apply for reexamination within six months after completion of the remedial course. After taking the remedial course, the candidate may be approved to retake the examination up to three additional times before the candidate is required to take remediation again.

"Remedial course" means a course that is approved by the board and meets the requirements of subchapter 8 and shall include a minimum of sixty hours of didactic instruction and sixty hours of clinical instruction.

Licensed Practical Nurse or Registered Nurse – Endorsement Applicants

• CURRENT APPLICATIONSWe will only accept the most current revised applications that are posted online. No "old" applications will be accepted. Submitting an outdated application will delay processing.






REQUIREMENTS:




INSTRUCTIONS:




•


•


•


NOTE:


• If you do not use this code, FPHIBrdNursing (not case sensitive), we will not be able to retrieve your report and you will have to go back to get fingerprinted and pay another fee.


• NATIONAL PRACTITIONERS DATA BANK SELF-QUERY REPORT

If you are applying for a Hawaii LPN or RN license and are licensed as an LPN or RN under the laws of another state, territory, or foreign country, you will be required to submit a self-query report from the National Practitioner Data Bank ("NPDB").

To obtain the report, go to the NPDB website at: www.npdb.hrsa.gov and click on Perform a Self-Query. If you are unable to go on-line, call NPDB at 1-800-767-6732 for assistance. After you receive this report, send the PDF original report to the Board of Nursing.

The NPDB self-query report is available for download. The Board of Nursing will accept either the ORIGINAL hard copy that is mailed to you from the NPDB or the ORIGINAL PDF emailed report. You will need to attach the PDF file in the email. Please forward the PDF report to [email protected]. Copies or “pictures” of the NPDB self-query report is not acceptable and we do not open secured files or links.

Advanced Practice Registered Nurse (“APRN”) Applicants

• CURRENT APPLICATIONSWe will only accept the most current revised applications that are posted online. No "old" applications will be accepted. Submitting an outdated application will delay processing.

• CURRENT HAWAII RN LICENSEIn order to obtain or maintain a Hawaii APRN license, you must have a current and valid Hawaii RN license.

If you are applying for both the Hawaii RN and APRN license, you may submit your applications at the same time and need not wait until a Hawaii RN license is issued to you.






REQUIREMENTS:




INSTRUCTIONS:




•


•


•


NOTE:




If you were previously fingerprinted in order to receive a Hawaii RN or LPN license after July 1, 2017, you need not be fingerprinted again when applying for the APRN license.

• NATIONAL PRACTITIONERS DATA BANK SELF-QUERY REPORT

If you are applying for a Hawaii LPN, RN license or APRN and are currently licensed or was licensed as an LPN, RN or APRN under the laws of another state, territory, or foreign country, you will be required to submit a self-query report from the National Practitioner Data Bank ("NPDB").

To obtain the report, go to the NPDB website at: www.npdb.hrsa.gov and click on Perform a Self-Query. If you are unable to go on-line, call NPDB at 1-800-767-6732 for

assistance. After you receive this report, send the PDF original report to the Board of Nursing.

The NPDB self-query report is available for download. The Board of Nursing will accept either the ORIGINAL hard copy that is mailed to you from the NPDB or the ORIGINAL PDF emailed report. You will need to attach the PDF file in the email. Please forward the downloaded PDF report to [email protected]. Copies or “pictures” of the NPDB self-query report is not acceptable and we do not open secured files or links.

Prescriptive Authority for Advanced Practice Registered Nurse (“APRN”) Licensees If you are currently licensed as a Hawaii APRN and wish to apply for prescriptive authority as a “privilege” under your APRN license, you must complete the application for “Advanced Practice Registered Nurse Prescriptive Authority”.

If you are applying for initial license as a Hawaii APRN with prescriptive authority, you may use the APRN license application and you do not need to complete this application. This is application is only for currently licensed Hawaii APRNs.

• CURRENT APPLICATIONSWe will only accept the most current revised applications that are posted online. No "old" applications will be accepted. Submitting an outdated application will delay processing. There are no fees for this application.

• CURRENT HAWAII RN AND APRN LICENSEIn order to apply for prescriptive authority, you must have a current and valid Hawaii RN and APRN license.


All applicants for a Hawaii nurse license and for prescriptive authority are required to be fingerprinted for a criminal history record check.




REQUIREMENTS:




INSTRUCTIONS:




•


•


•


NOTE:




If you were previously fingerprinted in order to receive a Hawaii LPN, RN or APRN license after July 1, 2017, you need not be fingerprinted again when applying for the APRN license.

• RENEWAL REQUIREMENTS FOR PRESCRIPTIVE AUTHORITY

Please be advised that the prescriptive authority you are applying for is a “privilege” attached to your APRN license and must be renewed.

At the time of renewal, you will be asked if you wish to “renew” your prescriptive authority. If you answer “yes”, your prescriptive authority will be renewed along with your APRN license. If you fail to indicate “yes” or leave blank, your prescriptive authority will NOT be renewed.

You will have until December 31 of the odd-numbered year to restore your prescriptive authority. If you do not restore your prescriptive authority by the end of December of the odd-numbered year, you will have to reapply as a new applicant for prescriptive authority and meet all current requirements.

Any APRN who fails to renew his or her prescriptive authority and continues to practice as an APRN with prescriptive authority shall be considered an illegal practitioner and shall be subject to penalties provided for by law.

REQUIREMENTS/INFORMATION - ADVANCED PRACTICE REGISTERED NURSES PRESCRIPTIVE AUTHORITY

Access this form via website at: cca.hawaii.gov/pvl

If you are NOT currently licensed as an Advanced Practice Registered Nurse (APRN) and is applying for APRN with prescriptive authority, then please complete the Application for APRN License, form NSG-23. This form is for currently licensed APRNs who wish to apply for prescriptive authority.

NO RECIPROCITY Hawaii does not reciprocate with any other state or jurisdiction. Each applicant is required to meet requirements according to Hawaii laws and rules.

PREREQUISITES Each applicant is required to have a current and unencumbered license as an Advanced Practice Registered Nurse ("APRN") and as a Registered Nurse ("RN") in Hawaii. Once approved, your prescriptive becomes a "special privilege" under your APRN license.

DOCUMENTS REQUIRED

1. Application form: We are creating a separate file for prescriptive authority recognition. As such, this file requires original documentation as required below. Similar documents that may be in Hawaii APRN recognition file will not be transferred unless the APRN license was granted no more than 12 months prior. 2. Graduate-level degree transcript: Arrange with your school to have your official transcript of a graduate-level degree in clinical nursing or nursing science sent directly to the Department of Commerce & Consumer Affairs ("DCCA"). 3. Certification of nursing practice specialty: Arrange with the Board recognized national certifying body to have proof of your current certification sent directly to DCCA. 4. Proof of education in advanced pharmacology, including advanced pharmacotherapeutics: Arrange with your educational institution or continuing education course provider to provide verification of the item you checked in question 3 of your application form. Refer to rules for continuing education requirements. To facilitate the review of your application, and to receive proper credit for your coursework, attach course descriptions from your college/university catalog or continuing education course provider. The applicant has the burden of proving he/she meets recognition requirements.

CRIMINAL HISTORY RECORD CHECK FEDERAL BUREAU OF INVESTIGATION ("FBI") REPORT

All applicants are required to submit to a FBI fingerprint check through the Hawaii Criminal Justice Data Center (HCJDC). To obtain a FBI national Criminal History Record check and the State of Hawaii Criminal History Record check, applicants shall be fingerprinted electronically at Fieldprint Inc. locations nationwide or any other fingerprinting agency approved to send electronic fingerprints to the Hawaii Criminal Justice Data Center ("HCJDC"). Please visit Fieldprint Inc. at: http://fieldprinthawaii.com to make an appointment, inquire about other available site locations on the Continental United States, or call (877) 614-4361. Fees for the FBI and the State of Hawaii Criminal History Record checks shall be paid directly to Fieldprint and will be electronically sent to the HCJDC.

(CONTINUED ON PAGE 2)

RX-01 1220R

NOTE: A license application must be filed within 30 days of the fingerprinting to ensure that the results are obtainable from the HCJDC. If the results are not obtainable, you will be required to obtain new fingerprints. Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. Your fingerprints will also be retained by the HCJDC and the FBI for all purposes and uses authorized for fingerprint submissions, which may include participation in the state and national rap back programs. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedure for obtaining a change, correction, or updating an FBI identification record are set forth in Title 28, CFR, 16.34.

CRIMINAL HISTORY RECORD CHECK FEDERAL BUREAU OF INVESTIGATION ("FBI") REPORT (cont'd)

DOCUMENTATION REQUIREMENTS FOR "YES" ANSWERS TO QUESTIONS (4), (5b), (5c)

The following documentation/materials must be submitted with the license application or submitted directly from the official source. Applications will not be processed without this documentation/materials.

1. If you answered "YES" to question #4, "Have you ever been convicted of a crime in any jurisdiction that has not been annulled or expunged?", you must submit the following:a) A detailed statement signed by you explaining the underlying circumstances that led to the

conviction(s);b) Certified copies of court documents related to the conviction that include but is not limited to

the indictment(s), judgments, disposition of the court, terms of sentence and sanctions. Also, if applicable, proof of compliance with any sanctions imposed by the court(s) i.e. proof of payment of fines, completion of course, etc; and

c) If you are currently on parole or probation, a certified copy of the terms of the parole or probation and a statement from your parole or probation officer as to your compliance with the court orders.

2. If you answered "YES" to question #5b, "Has any of the above prescriptive authority, recognition, or licenses ever been revoked, suspended, or otherwise subject to disciplinary action?", you must submit the following:

a) A detailed statement signed by you explaining the underlying circumstances that led to the disciplinary action(s); and

b) Certified copies of any documents from the agency (other Board of Nursing) including final orders, petitions, complaints, findings of fact and conclusions of law, consent orders, and any other relevant documents.

3. If you answered "YES" to question #5c, "Are you presently being investigated or is any disciplinary action pending against any of the licenses, prescriptive authority, recognitions, certifications, or registrations you hold?", you must submit the following:

a) A detailed statement signed by you explaining the underlying circumstances that led to the disciplinary action(s); and

b) Certified copies of any documents from the agency (other Board of Nursing) including petitions, complaints, findings of fact and conclusions of law, consent orders, and any other relevant documents.

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If you previously filed an application for nurse license and provided the previous information and was approved by the Board and have not had any subsequent convictions, disciplinary actions or are currently being investigated, then you may submit a signed statement indicating that the information was previously disclosed and documents submitted and that there has not been any subsequent convictions, disciplinary actions or pending investigations. Also, for any pending disciplinary actions or investigations, you are required to report the outcome with documentation of the investigation within thirty (30) days of the disposition.


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If for any reason you are denied the recognition you are applying for, you may be entitled to a hearing as provided by Title 16, Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes. Your written request for a hearing must be directed to the agency that denied your application, and must be made within 60 days of notification that your application for recognition has been denied.

Board of Nursing Phone: (808) 586-3000 DCCA, PVL Licensing Branch P.O. Box 3469 Toll free voice access numbers for the neighbor islands: Honolulu, HI 96801 Kauai - 274-3141 Ext. 6-3000 OR Maui - 984-2400 Ext. 6-3000 Deliver to office location at: Hawaii - 974-4000 Ext. 6-3000 335 Merchant St., Room 301 Molokai - 1-800-468-4644 Ext. 6-3000 Honolulu, HI 96813 Lanai - 1-800-468-4644 Ext. 6-3000

MAILING ADDRESS

ABANDONED APPLICATIONS

Pursuant to HRS §436B-9 your application shall be considered abandoned and shall be destroyed if you fail to provide evidence of continued efforts to complete the licensing process for two consecutive years. The failure to provide evidence of continued efforts includes but is not limited to: (1) failure to submit any required information and documents requested by the licensing authority within two consecutive years from the last date the documents and information were requested, or (2) failure to complete any additional requirements for licensure that remain after approval of your application, such as attempting to complete an exam requirement, within two consecutive years from the date your application was approved, or (3) failure to provide the licensing authority with any written communication during two consecutive years indicating that you are attempting to complete the licensing process. If an application is deemed abandoned the applicant shall be required to reapply for licensure and comply with the licensing requirements in effect at the time of the reapplication.

LAWS AND RULES An APRN with prescriptive authority is held accountable for knowing and complying with the laws and rules of advanced practice registered nurse prescriptive authority practice as failure to comply may result in disciplinary action. Obtain copies by submitting a written request to APRN-RX Authority, Commerce and Consumer Affairs, P.O. Box 3469, Honolulu, HI 96801. Please indicate the specific chapters in your request. - Nurses, Hawaii Revised Statutes, Chapter 457 - Nurses, Hawaii Administrative Rules, Title 16, Chapter 89 - Professional & Vocational Licensing Law, Hawaii Revised Statutes, Chapter 436B - Food, Drugs & Cosmetics, Hawaii Revised Statutes, Chapter 328 - Uniform Controlled Substances Act, Chapter 329 The laws and rules are also posted on the website at: cca.hawaii.gov/pvl/boards/nursing/statute_rules.

ADDRESS CHANGES

Report your change of address in writing. Report each change of address separately, and the effective date of change.

NOTE: One of the numerous legal requirements that you must meet in order for your new recognition to be issued is the payment of fees as set forth in this application. You may be sent a recognition certificate before the payment you sent us for your required fees is honored by your bank. If your payment is dishonored, you will have failed to pay the required RX fee and your recognition will not be valid, and you may not do business under that recognition. Also, a $25.00 service charge shall be assessed for payments that are dishonored for any reason.

FEES

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All APRNs with prescriptive authority, regardless of when issued, expire on June 30 of each odd-numbered year and are subject to renewal by the expiration date. A "Renewal postcard" is mailed approximately 60 days prior to the expiration date to your last address on file with DCCA. DCCA is not responsible for non-receipt of any mail. The burden is on the APRN to ensure that his/her APRN license is kept current. Refer to section 16-89-123, Hawaii Administrative Rules, for license renewal requirements on current certification, continuing education, etc.

RENEWAL OF PRESCRIPTIVE AUTHORITY

ORAL CODE DESIGNATION

The Department of Public Safety, Narcotics Enforcement Division ("NED"), has jurisdiction over assignment of your oral code designation. You may contact the office at (808) 837-8470.

RELEASE OF INFORMATION

If an agency or individual is assisting you with the licensure process, we will not be able to release any information to them unless you provide us with authorization. If you wish to do so, please complete the portion on Release of Information to Third Party, sign and date it.

MAINTENANCE OF LICENSE

Any encumbrance on one nurse license shall automatically and similarly affect any other nursing license, recognition as an APRN, and the prescriptive authority held by that nurse.

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

APPLICATION - ADVANCED PRACTICE REGISTERED NURSE PRESCRIPTIVE AUTHORITY

Read the instructions before completing this form. Print legibly or type.

Legal Name (First, Middle) (Last)

OFF

ICE

USE

ON

LY

Category Code:

RN - Exp 6/30/_____ APRN - Exp 6/30/_____

Date Effective:RX -

Recognition No.

Approval date Ineligible Initial

Other Names Used (Include maiden name)

Residence Address (Include Apt. No., City, State & Zip Code) - REQUIRED

Mailing Address (Only if different from above)

Social Security Number

Date of Birth

Hawaii APRN Recognition No.APRN -

Effective date of Hawaii Recognition

Board of Nursing Approved Specialty/Code:

Hawaii RN License No.RN -

Check answers and provide details when required:

1. Have you arranged for an official transcript of a graduate-level degree in clinical nursing or nursing science, be sent directly from the school to DCCA? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

2. Have you arranged for verification of current certification in your practice specialty, be sent from a national certifying body recognized by the Hawaii Board of Nursing to DCCA? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Name of school: Graduation date: Date requested:

Yes No

Name of certifying body: Date requested:

3. Which one of the following have you successfully completed within the three-year period immediately preceding this application AND have you enclosed verification of such successful completion from your educational institution or national certifying body?

At least 30 contact hours*, as part of a graduate-level degree in clinical nursing or nursing science program from an accredited college/university, of advanced pharmacology education, including advanced pharmacotherapeutics that is integrated into the curriculum? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

a.

b.

c.

OR

At least 30 contact hours* of advanced pharmacology, including advanced pharmacotherapeutics, from an accredited college/university? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OR

At least 30 contact hours* of continuing education from a Hawaii Board of Nursing approved recognized certifying body, in advanced pharmacology, including advanced pharmacotherapeutics related to your practice specialty? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RX-02 1220R


Name of school/provider:

*Contact hours means a minimum of fifty minutes of actual organized instruction. Academic credit shall be converted to contact hours as (1) one quarter academic credit = 10 contact hours, or (2) one semester academic credit = 15 contact hours.

Yes No

Yes No

Yes No

PERSONAL E-Mail Address Phone No. (Daytime)

Access this form via website at: cca.hawaii.gov/pvl

CBC: EO:

• Provide date you were fingerprinted to obtain the national (FBI) and State Criminal History Record Check. Date:

4. Have you ever been convicted of a crime in any jurisdiction that has not been annulled or expunged? . . . . . . . . . . . . . . . . . . . . Yes No

If "YES", arrange to have certified court documentation on the date, place, violation for each conviction and fulfillment of conditions of each sentence sent directly to DCCA.

5a. List all states in which you are currently recognized or licensed as an APRN-RX:

State:

State:

State:

No.

No.

No.

Expiration date:

Expiration date:

Expiration date:

b. Has any of the above prescriptive authority, recognition, or licenses ever been revoked, suspended, or otherwise subject to disciplinary action? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

If "YES", arrange to have certified documents from the state in which disciplinary action was taken, sent directly to DCCA. (Include Findings of Fact, Conclusion of Law, Recommended Order, Final Order, and whether you have been reinstated. If re-instated, date and conditions of license.)

c. Are you presently being investigated or is any disciplinary action pending against any of the licenses, prescriptive authority, recognitions, certifications, or registrations you hold? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

If "YES", arrange to have certified documents from the state in which disciplinary action or investigation is pending against you, sent directly to DCCA.

Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. Your fingerprints will also be retained by the HCJDC and the FBI for all purposes and uses authorized for fingerprint submissions, which may include participation in the state and national rap back programs. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedure for obtaining a change, correction, or updating an FBI identification record are set forth in Title 28, CFR, 16.34.

AFFIDAVIT OF APPLICANT: I hereby certify that the statements, answers and representations made in this application and in the documents attached are true and correct. I understand that any misrepresentation is grounds for refusal to grant or subsequent revocation of recognition and is a misdemeanor (Section 710-1017, Sections 436B-19 and 457-12, Hawaii Revised Statutes). I also certify that I have read, understand, and agree to comply with Chapter 457, Hawaii Revised Statutes and Chapter 89, Hawaii Administrative Rules.

Signature of Applicant Date

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Print Applicant Name: Date:

Release of Information to Third Party: To assist me in the licensing process, I authorize DCCA's staff to release any and all information regarding my application (including but not limited to, application status) to the following third party:

Print name of individual who is assisting you:

Signature of Applicant Date

Pursuant to §436B-9, Hawaii Revised Statutes, your application shall be considered abandoned and shall be destroyed if you fail to provide evidence of continued efforts to complete the licensing process for two consecutive years. The failure to provide evidence of continued efforts includes, but is not limited to: (1) failure to submit any required information and documents requested by the licensing authority within two consecutive years from the last date the documents and information were requested, or (2) failure to complete any additional requirements for licensure that remain after approval of your application, such as attempting to complete an examination requirement, within two consecutive years from the date your application was approved, or (3) failure to provide the licensing authority with any written communication during two consecutive years indicating that you are attempting to complete the licensing process. If an application is deemed abandoned, the applicant shall be required to reapply for licensure and comply with the licensing requirements in effect at the time of the reapplication. Frequently Asked Questions regarding Abandoned Applications 1) Q: If after receiving my application the board or program requests additional information, how much time do I have to provide them with the requested information before my application is deemed abandoned? A: You have two years from the date the information is requested. 2) Q: If I am an applicant who is required to take a licensing examination in order to complete the licensing process and my application to take the licensing examination is approved, how much time do I have to complete the examination requirement before my application is abandoned? A: You must make an attempt to take the examination within two years from the date your application is approved. 3) Q: What is meant by "attempt to take the examination?" A: You must register and take the examination. 4) Q: If the statutes or rules of the boards or programs do not set time limits on taking and passing the examination, and the only requirement left for me to become licensed is to pass the examination, and within the two year period I should fail the examination, re-register for the examination, but fail again, will my application be abandoned because I could not pass the examination within two years? A: Your application will not be abandoned because you would have demonstrated your efforts to take the examination by registering for and taking the examination. (NOTE: Our office will only be notified of your efforts if you take the examination as a Hawaii candidate. Examination results will not automatically be provided to our office if you sit for the examination via another state board. Therefore, if you are in this situation, please arrange for the test results to be sent to us). 5) Q: What does it mean if my application is abandoned? A: It means that your application is no longer valid, will be destroyed, and you shall be required to reapply and comply with the requirements for licensure at the time of the reapplication. To reapply, you must submit a new application and you will be required to comply with the licensing requirements and pay fees that are in effect at the time you submit your new application. 12/10

7) Q: Will any of the documents that supplemented my first application be saved in case I need to reapply? A: No. When you reapply, you will need to again provide us with documentation. 8) Q: Will the application fee that I paid with my first application carry over to cover the application fee for my new application? A: No. You will be required to again pay the non-refundable application fee. 9) Q: If my application has not been destroyed does this mean that it has not yet been deemed "abandoned?" A: No. Simply because an application has not been destroyed does not mean that it has not been deemed abandoned. 10) Q: If I am currently unable to complete the licensing process (eg., no continued effort), how do I prevent my application from being abandoned? A: You have two years to complete the licensing process. However, if you are unable to show continued effort for two consecutive years but you still intend to complete the licensing process, you must send a written communication to the board or program prior to the two year expiration explaining why you are unable to complete the licensing process within two years. Your written communication shall also request approval to complete the licensing process by a specific date after the two year expiration. You will be advised whether your request is approved or disapproved. If disapproved, your application will be destroyed and you will need to reapply for licensure. 11) Q: Who do I contact to find out if my application is soon to be abandoned? A: You may contact the Licensing Branch at (808) 586-3000.

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6) Q: Will you be providing a notice to me before my application is abandoned? A: It is not required that we notify you before your application is abandoned. However, some boards and programs have taken the initiative to send out notifications.

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