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Fill in Your Vermont Nurse Renewal Form

The Vermont Nurse Renewal form is a crucial document for registered nurses seeking to maintain their professional licensure in Vermont. This form must be submitted to the Vermont Secretary of State’s Office of Professional Regulation prior to the expiration of the current license. Timely submission ensures compliance and avoids potential penalties associated with late renewals.

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For nurses practicing in Vermont, maintaining an active license is crucial, and the Vermont Nurse Renewal form is the key to ensuring that status. This form, which must be submitted to the Office of Professional Regulation, serves multiple purposes, from verifying personal information to confirming compliance with state regulations. The renewal application requires a non-refundable fee of $95, and it must be accompanied by a check or money order made out to the Vermont Secretary of State. Timeliness is essential; if the application is not received by the expiration date, a late fee may apply, escalating with each month past due. The form also mandates that applicants declare their standing regarding child support, taxes, and any unpaid judgments, ensuring that all practicing nurses uphold their professional responsibilities. Furthermore, it includes sections that assess the applicant's fitness to practice, requiring disclosure of any disciplinary actions or criminal convictions. Lastly, the form emphasizes the importance of documenting nursing practice hours, with specific guidelines for both private and volunteer duties, thereby reinforcing the commitment to safe and effective patient care.

⇩ Vermont Nurse Renewal PDF Form

Dos and Don'ts

When filling out the Vermont Nurse Renewal form, it's essential to follow specific guidelines to ensure a smooth renewal process. Here are eight things to do and avoid:

Do double-check your personal information for accuracy, including your name, address, and license number.
Do attach all necessary documentation if your name has changed since your last renewal.
Do submit your application and payment before the expiration date to avoid late fees.
Do provide a detailed explanation for any "Yes" answers in the credential and fitness questions.
Don't forget to sign and date your application; an unsigned application may be rejected.
Don't submit your application via fax, as it is not accepted.
Don't leave any sections of the form blank; ensure all required fields are completed.
Don't ignore the late renewal penalties; they increase significantly after 30 days.

Similar forms

The Vermont Nurse Renewal form shares similarities with the application for a Medical License Renewal. Both documents require personal identification details, including the applicant's name, address, and license number. Additionally, each form mandates the submission of a renewal fee, which is typically non-refundable. Both applications also include sections that address any changes in the applicant's legal status, such as name changes or disciplinary actions taken against their license. This ensures that the licensing board has up-to-date and accurate information regarding the applicant's professional standing.

Another document similar to the Vermont Nurse Renewal form is the Pharmacy License Renewal application. Like the nurse renewal, it requires demographic information and a declaration of compliance with state regulations. Both forms also emphasize the importance of maintaining an active license to practice legally. Furthermore, they both outline penalties for late submissions, ensuring that applicants are aware of the consequences of failing to renew on time.

The Dental License Renewal form closely resembles the Vermont Nurse Renewal form in structure and purpose. Both documents require applicants to confirm their compliance with state laws and regulations. They also include sections for reporting any legal issues or disciplinary actions that may affect the applicant's ability to practice. The renewal fees and the necessity for timely submission are common features in both applications, reinforcing the importance of adhering to state requirements.

The Physical Therapist License Renewal application is another document similar to the Vermont Nurse Renewal form. Both require the applicant to provide proof of continuing education and recent practice hours. They also include sections that inquire about any legal or disciplinary actions taken against the applicant. The requirement for a renewal fee and the potential penalties for late submissions are consistent across both forms, highlighting the critical nature of maintaining licensure.

In addition, the Occupational Therapy License Renewal form shares similarities with the Vermont Nurse Renewal form. Both applications ask for personal information, including the applicant's social security number and contact details. They also require the applicant to affirm their good standing in relation to child support and tax compliance. The structure of both documents emphasizes the need for accurate and truthful reporting, as any discrepancies can lead to penalties or denial of renewal.

For those preparing legal documents related to professional practices, it is essential to understand various forms, including the Hold Harmless Agreement form, which serves to protect parties from potential liabilities, ensuring a safer environment during activities that entail risks.

The Veterinary License Renewal application also mirrors the Vermont Nurse Renewal form in its requirements. Both documents necessitate the submission of a renewal fee and include sections for reporting any legal issues that could impact the applicant's professional standing. They emphasize the importance of providing accurate information and maintaining compliance with state regulations, ensuring that practitioners remain accountable for their professional conduct.

The Real Estate License Renewal application is yet another document that is similar in nature to the Vermont Nurse Renewal form. Both require the applicant to provide demographic information and attest to their compliance with state regulations. Each form includes a section for reporting any legal issues or disciplinary actions that may affect the applicant's ability to practice. The emphasis on timely renewal and the associated fees are common features that highlight the importance of maintaining an active license.

Additionally, the Social Work License Renewal application shares structural similarities with the Vermont Nurse Renewal form. Both require personal information and a declaration of good standing regarding child support and tax compliance. They also include sections for reporting any disciplinary actions or legal issues that could affect the applicant's license. The requirement for a renewal fee and the consequences of late submission are consistent across both forms, reinforcing the need for timely and accurate reporting.

Lastly, the Counseling License Renewal application reflects similarities with the Vermont Nurse Renewal form. Both documents require the applicant to provide personal information, including social security numbers and contact details. Each application includes sections for reporting any legal issues or disciplinary actions that may affect the applicant's ability to practice. The emphasis on maintaining compliance with state regulations and the requirement for a renewal fee are common elements that ensure practitioners remain accountable for their professional conduct.

Common mistakes

Incomplete Personal Information: Failing to fill out all required fields, such as name, address, and contact details, can lead to delays in processing your renewal.
Incorrect Payment Method: Submitting a payment that is not a check or money order made out to the "Vermont Secretary of State" may result in your application being rejected.
Missing Supporting Documents: If there has been a name change, neglecting to attach the necessary documentation (like a marriage or divorce certificate) can prevent your renewal from being processed.
Ignoring Deadlines: Not submitting the renewal application by the expiration date can incur late fees. It’s important to be aware of the deadlines to avoid additional costs.
Failure to Report Changes: Not updating your address or any changes in your professional status within 30 days can be considered unprofessional conduct.
Inaccurate Declarations: Misreporting your status regarding child support, taxes, or any disciplinary actions can lead to complications or denial of your renewal application.
Neglecting to Sign: Forgetting to sign the application can result in it being returned. Always double-check that your signature is included.

Document Preview

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.
right.	Street/Apt #
	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
Office of a change of name or address within	Country
thirty (30) days (3 V.S.A. §129a(a)(14)).	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.

Street/Apt #

Suite/Department/Floor

City/State/Zip

Country

Phone: (

)

Cell Phone: (

)

E-Mail Address:

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, 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 good standing*

I am in compliance with a payment plan approved by the Vermont Department of Taxes

I am NOT in good standing*

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: ___________________________

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?		Yes	No

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?		Yes	No

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?		Yes	No
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?
		Yes	No
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		Yes	No

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.”)		Yes	No

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)?
		Yes	No
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?
	Yes	No
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?	Yes	No
	Yes	No
If “Yes,” you must provide a detailed written explanation.

Are you currently addicted to or in any way dependent on alcohol or habit forming drugs?
	Yes	No
If “Yes,” you must provide a detailed written explanation.

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?	Yes	No
	Yes	No
If “Yes,” please provide the contract/stipulation under which you are practicing.

Name (print): ___________________________________

License Number: ___________________________

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.

Name (print): ___________________________________

License Number: ___________________________

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.

Yes

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 #
______________________________	_	_	_ ----____________________________

Name (print): ___________________________________

License Number: ___________________________

Office of Professional Regulation

Vermont Secretary of State

Attn: Renewal Clerk

89 Main St. 3rd Floor

Montpelier, VT 05620-3420

Phone: (802) 828-1505 Fax: (802) 828-2465

www.vtprofessionals.org

Vermont Office of Professional Regulation Survey (optional)

2013 Renewal

License #: __________ ----_______________________________

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.

Yes

2.Would you be willing to serve as an Ad Hoc 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.

Yes

3.Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession?

Yes

If you answered “Yes” to the question above, what is your area of expertise?

Name (print): ___________________________________

License Number: ___________________________

Documents used along the form

The Vermont Nurse Renewal form is an essential document for registered nurses looking to maintain their licensure in Vermont. Along with this form, several other documents may be required to ensure a smooth renewal process. Below is a list of these additional forms and documents, each with a brief description.

RN Practice History Record: This form helps document the practice hours of a registered nurse over the past five years. It is crucial for verifying compliance with the practice experience requirement.
Proof of Continuing Education: Many states require evidence of completed continuing education courses as part of the renewal process. This document shows that the nurse has kept their skills and knowledge up to date.
Name Change Documentation: If a nurse has changed their name since the last renewal, they must provide legal documentation, such as a marriage license or divorce decree, to update their records.
Texas Bill of Sale: For those in Texas, a Bill of Sale is crucial for the legal verification of the purchase and sale of items, ensuring both buyer and seller are protected. More information can be found at TopTemplates.info.
Child Support Compliance Form: This form indicates whether the applicant is in good standing with child support obligations. It is a requirement for renewal in many states, including Vermont.
Tax Compliance Form: Similar to the child support form, this document verifies that the nurse is in compliance with state tax obligations, which is necessary for renewal.
Criminal Background Check: Depending on the circumstances, a criminal background check may be required. This document helps ensure that the nurse has not committed any offenses that would disqualify them from practicing.
Disciplinary Action Documentation: If a nurse has faced any disciplinary actions against their license, they must provide documentation regarding the nature and resolution of those actions.
Official Employment Verification Letters: These letters confirm the nurse’s employment history and practice hours. They are particularly important for those who have worked in private duty or volunteer positions.
Affidavit of Practice: This sworn statement may be required to affirm the nurse's practice history and compliance with renewal requirements, particularly if there are any discrepancies in the application.

Gathering these documents can help facilitate a successful renewal process for registered nurses in Vermont. By ensuring all necessary paperwork is complete and accurate, nurses can focus on their essential role in providing care to their patients.

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