RN EXAMINATION APPLICATION INSTRUCTIONS EDUCATED OUTSIDE US

IMPORTANT INFORMATION
About your ability to practice nursing
You may not work as a nurse in Missouri without a current Missouri nursing license. This includes
orientation as well as any other employment in which you are being compensated as a nurse, regardless
of whether or not the position includes hands on patient care.
Nurse Licensure Compact
Missouri is a member of the Nurse Licensure Compact which allows nurses licensed in Missouri
to practice in other compact states. A nurse may hold only one compact license and it must be issued by
his/her state of primary residence. If you declare your primary state of residence to be a compact state
other than Missouri and you will not be moving to Missouri, you should not apply for licensure in
Missouri. If you currently reside in a compact state other than Missouri and will change your primary
residence to Missouri within the next 90 days, you may declare primary residency as Missouri and apply
for a license. You may be required to provide proof of residency, which may include a Missouri drivers
license, voter registration or income tax return. If you declare a non-compact state as your state of
primary residence, and you meet all other requirements for licensure in Missouri, you will receive a
single-state license valid for practice only in Missouri. For a list of states participating in the Compact or
additional information about the Compact go to http://www.ncsbn.org/
What YOU Must Submit To The Board Of Nursing Office
Completed, signed and notarized application
One 2x2 signed photograph
$45.00 fee - make the fee payable to the Missouri State Board of Nursing. The fee may be a money
order, cashiers check or personal check. The fee is non-refundable.
Refer to the enclosed Credentials List for other documents that you must submit to this office. All
credentials must be in English or English translation by an authorized person. Translations must be
attached to a copy of the original document.
Criminal background checks Do this at least two weeks after you submit your application to the
Board
Step 1: Go to www.machs.mo.gov and register using the 4 digit registration number of 0001 (three
zeroes followed by a one). After you register, you will receive a TCN number. You will want to register
with the fingerprint portal.
Step 2: Write down your TCN number.
Step 3: Click on Fingerprint Sites near the top of the web site at www.machs.mo.gov to find a fingerprint
location. Once you click on Fingerprint Sites, a map will be displayed. Click on the county you desire,
then click on a preferred location. You will then see the location address and hours of operation.
Step 4: Take your TCN number and a valid government issued ID with you to the fingerprint location.
Step 5: Get your prints taken and obtain a fingerprinting receipt.
Step 6: Retain your receipt for your records.
If you DO NOT register online first and take your TCN number with you to the fingerprint location, you
WILL experience long wait times.
If you are not in Missouri and do not wish to drive to a Missouri fingerprint location, you still need to
register as indicated in step 1 above. We recommend that you make payment online. You will then need
to go to a law enforcement agency and obtain two inked fingerprint cards captured on a standard FBI258 applicant fingerprint card. Write down the TCN number on the back of your Fingerprint Cards. Mail

your cards to: 3M Cogent, Missouri CardScan, 5025 Bradenton Ave, Suite A, Dublin, OH 43017. To
protect your identity, we recommend that you never put outgoing mail containing your personal
identifying information in your mailbox. You should take it directly to a post office or drop it in a postal
box. Do not mail the fingerprint cards to our office; we will destroy the cards and you will have to get
printed again.
The total fee is $44.80. This includes a State of Missouri search, a FBI search and the Cogent fee.
Cogent is the state's vendor that processes fingerprints.
ADDITIONAL INFORMATION
Applicants for licensure must meet the same minimum requirements as graduates of Missouri
schools of nursing. The licensure process is time consuming and may take several months to complete.
You may not work as a nurse in the State of Missouri until you have passed the
examination and are licensed. The Missouri State Board of Nursing has no legal basis to issue a
temporary permit.
When all documents requested have been received, your application will be evaluated. If you are
found eligible to take the NCLEX examination you will be notified in writing. You will then need to
register for NCLEX online at http://www.pearsonvue.com/nclex.
NOTICE
Effective July 1, 2003, all persons and business entities renewing a license with the Division of
Professional Registration are required to have paid all state income taxes, and also are required to have
filed all necessary state income tax returns for the preceding three years. If you have failed to pay your
taxes or have failed to file your tax returns your license will be subject to immediate revocation within
90 days of being notified by the Missouri Department of Revenue of any delinquency or failure to file.
This requirement was enacted in House Bill 600 of the 92nd General Assembly (2003), and was signed
into law by the Governor on July 1, 2003.
All persons and business entities renewing a license with the Division of Professional
Registration are required to have paid all state income taxes, and also are required to have filed all
necessary state income tax returns in the preceding three (3) years. If you have failed to pay your taxes
or failed to file your tax returns, your license will be subject to immediate suspension within ninety (90)
days of being notified by the Missouri Department of Revenue of any delinquency or failure to file
pursuant to 324.010 RSMo.
You cannot be granted a license until you provide a Unites States social security number. Pursuant to 42
U.S.C. Section 666(1)(13), federal law requires each state to institute procedures to obtain the social
security number of any applicant for a professional license or occupational license and requires that the
social security number be recorded on the application.
Furthermore, section 324.024 RSMo, requires every application for a license, certificate, registration, or
permit or renewal of a license, certificate, registration, or permit issued in this statecontain the Social
Security of the applicant. This provision shall not apply to an original application for a license,
certificate, registration, or permit submitted by a citizen of a foreign country who has never been issued
a Social Security number and who previously has not been licensed by any other state, United States
territory, or federal agency. A citizen of a foreign country applying for licensure with the division of
professional registration shall be required to submit his or her visa or passport identification number in
lieu of the Social Security number.
1/2015

Credentials List for Foreign-Educated Registered Nurse Applicants

1. Course-by-Course evaluation report received directly from a foreign credentials

evaluation service approved by the Board. Refer to the reverse side of this
Credentials List for a list of foreign credentials evaluation services approved by the
Board. The evaluation must include verification of your license from your original
country/territory of licensure.
2. Photostatic copy of birth certificate. If a copy of birth certificate is not available, copy
of baptismal certificate, passport or notarized statement from an authorized agency
will be accepted as verification of name, date and place of birth.
3. Photostatic copy of marriage license/certificate (if applicable).
4. Evidence of English-language proficiency by any of the following:
a) Test of English as a Foreign Language (TOEFL) www.toefl.org with a passing
score of 540 on the paper examination or a passing score of 76 for the internetbased examination; or
b) Test of English for International Communication (TOEIC) www.toeic.com with a
passing score of 725; or
c) International English Language Testing System (IELTS) www.ielts.org with a
passing score in the academic module of 6.5 and the Spoken Band score of 7
5. Photostatic copy of original license issued by the licensing/certifying agency where
original licensure/registration was secured by examination.
6. Completed Application for License as a Registered Professional Nurse by
Examination, application fee and one (1) two inch by two inch (2 x 2) photograph.
05/2014

Foreign Credentials Evaluation Services

Approved by the Missouri State Board of Nursing
All reports must come to the Board of Nursing office directly from the
evaluation service.
Commission on Graduates of Foreign Nursing Schools
(Credentials Evaluation Service)
3600 Market Street Suite 400
Philadelphia, PA 19104-2651
(215) 349-8767
Web: www.cgfns.org
*Credential Evaluation Service Professional Report
Educational Records Evaluation Service, Inc.
601 University Avenue, Suite 127
Sacramento, CA USA 95825-6738
Phone: (866) 411-3737 or (866) 411-ERES
FAX: (916) 921-0793
Web: www.eres.com
*Nursing Licensure Report
International Education Research Foundation, Inc.
Post Office Box 3665
Culver City, CA USA 90231-3665
Phone: (310) 258-9451
Fax: (310) 342-7086
Web: www.ierf.org
*Nursing Licensure Report
Josef Silny & Associates, Inc.
International Education Consultants
7101 SW 102 Avenue
Miami, FL 33173
Phone: (305) 273-1616
Fax: (305) 273-1338
Web: www.jsilny.com
*Nursing Course-by-Course
*Name of the report required by the Missouri State Board of Nursing.
You will have to contact the credentials evaluation service to obtain an
application. Fees will differ with each evaluation service. You may want to
contact each one to determine the fees required for the evaluation.

NONCRIMINAL JUSTICE APPLICANT'S PRIVACY RIGHTS

As an applicant who is the subject of a national fingerprint-based criminal history record check for a
noncriminal justice purpose (such as an application for a job or license, an immigration or naturalization
matter, security clearance, or adoption), you have certain rights which are discussed below.
You must be provided written notification1 that your fingerprints will be used to check the
criminal history record of the FBI.
If you have a criminal history record, the officials making a determination of your suitability for
the job, license, or other benefit must provide you the opportunity to complete or challenge the
accuracy of the information in the record.
The officials must advise you that the procedures for obtaining a change, correction, or updating
of your criminal history record are set forth at Title 28, Code of Federal Regulations (CFR),
Section 16.34.
If you have a criminal history record, you should be afforded a reasonable amount of time to
correct or complete the record (or decline to do so) before the officials deny you the job,
license, or other benefit based on information in the criminal history record.2
You have the right to expect that officials receiving the results of the criminal history record check will
use it only for authorized purposes and will not retain or disseminate it in violation of federal statute,
regulation or executive order, or rule, procedure or standard established by the National Crime
Prevention and Privacy Compact Council.3
If agency policy permits, the officials may provide you with a copy of your FBI criminal
history record for review and possible challenge. If agency policy does not permit it to
provide you a copy of the record, you may obtain a copy of the record by submitting
fingerprints and a fee to the FBI. Information regarding this process may be obtained at
http://www.fbi.gov/about-us/cjis/background-checks.
If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should
send your challenge to the agency that contributed the questioned information to the FBI. Alternatively,
you may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency
that contributed the questioned information and request the agency to verify or correct the challenged
entry. Upon receipt of an official communication from that agency, the FBI will make any necessary
changes/corrections to your record in accordance with the information supplied by that agency. (See 28
CFR 16.30 through 16.34.)

Written notification includes electronic notification, but excludes oral notification.

See 28 CFR 50.12(b).
3
See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 42 U.S.C. 14616, Article IV9c); 28 CFR 20.21(c), 20.33(d) and 906.2(d).
2

state of missouri
division of professional registration

application for license as a

registered professional nurse
by examination

application fee is non-refundable. application is

retired and void if requirements for licensure
are not met Within one year from the date that
the application Was notarized and a neW
application and fee Will need to be submitted to
be considered for licensure.

section i - profile information

fullname

(last)

missouri state board of nursing

p.o. box 656
Jeffersoncity, missouri 65102-0656
(573) 751-0681
Website: http://pr.mo.gov
email: nursing@pr.mo.gov

text telephone (tt)

1-800-735-2966
(hearing impaired)

lic. app. by

rn-x

for office use only

license date

app

license number

transcript

mshp

de

fbi

checK

mo

(first)

cash

deposited

(middle)

(maiden)

previous or other name(s)

primary residence (Where you vote, pay federal taxes, obtain a drivers license) physical address required, po boxes are not acceptable
city

state

zip code

state

zip code

mailing address (if different than primary residence) street or p.o. box
city
date of birth
month

day

year

place of birth (city)

**social security no. (mandatory, used for identification purposes only)

internet e-mail address (optional please print)

(state)

(county)

mothers maiden last name

telephone no. - home

telephone no. - WorK

fax number (optional)

section ii - basic professional nursing education

professional school of nursing
address (city)
type of program

baccalaureate
other (specify) 4

(state)

diploma

graduation date

associate degree

section iii - references

list the name, address and telephone number of two individuals who will always know where to reach you and indicate their relationship to
you. the references should not have the same daytime telephone number. this information will be used to contact you, if necessary.

name

telephone no.

address

relationship

name

telephone no.

address

relationship

*primary state of residence means the state of a persons declared fixed permanent and principal home for legal purposes; domicile. the following items could be requested as
proof of primary state of residence; drivers license, voter registration card, federal income tax return.

mo 375-0239 (12-13)

section iV - screening questions

absolute and complete candor is required.

if you are in doubt WHetHer or not to report, you sHould report it.
1.

have you ever been issued a professional license, certification, registration, or permit by any state, united
states, territory, province or foreign country?
if yes, identify type of license, WHen issued and by WHom.

yes

no

1a. are you currently a participant in a state board/designee monitoring program including alternative to
discipline, diversion or a peer assistance program?
if yes, proVide a Written explanation including tHe state, dates and reason for
participation.

yes

no

1b. have you ever been terminated for an alternative to discipline, diversion, or a peer assistance program due
to unsuccessful completion?
if yes, proVide a Written explanation including tHe state, dates, and reasons for
participation and termination.

yes

no

2.
3.

have you ever been denied a professional license, certification, registration or permit?
ifyes, explainfullyinaseparatenotariZedstatement.

yes
yes

no

4.

are you presently being investigated or is any disciplinary action pending against any professional license,
certification, registration, or permit you hold?
ifyes, explainfullyinaseparate notariZedstatement.

yes

no

have you ever voluntarily surrendered or resigned any professional license, certification, registration, or permit?
if yes, explain fully in a separate notariZed statement.

have you ever been convicted, adjudged guilty by a court, pled guilty, pled nolo contendere or entered an alford
plea to any crime, whether or not sentence was imposed excluding traffic violations? (this includes any crime
where the disposition was a suspended imposition of sentence (sis), or a suspended execution of sentence
(ses), or if you pled guilty but were placed in an alternative or diversion court, including drug or dWi court.)
if yes, explain fully in a separate notariZed statement and proVide certified
copies of court documents (i.e. docKet sHeet, complaint, and final disposition).

yes
yes

no

have you ever been convicted, adjudged guilty by a court, pled guilty, pled nolo contendere or entered an alford
plea to any traffic offense resulting from or related to the use of drugs or alcohol, whether or not sentence was
imposed? (this includes a disposition of a suspended imposition of sentence (sis), suspended execution of
sentence (ses), or placement in a post plea alternative or diversion court and includes municipal charges of
driving while intoxicated, driving under the influence and/or driving with excessive blood alcohol content.)
if yes, explain fully in a separate notariZed statement and proVide certified
copies of court documents (i.e. docKet sHeet, complaint, and final disposition).

yes

no

yes

no

are you now being treated, or have you been treated within the past five years, through a drug or alcohol
rehabilitation program?
if yes, explain fully in a separate notariZed statement and proVide tHe discHarge
summary or otHer official documentation tHat sHoWs your diagnosis, prognosis,
and treatment plan.

yes

no

11. have you ever been placed on an employee disqualification list or other related restriction of finding pertaining
to employment within a health-related profession issued by any state or federal government or agency?
if yes, explain fully on a separate notariZed statement.

yes
yes

no

5.
6.

7.

8.
9.

have you ever had any professional license, certification, registration, or permit revoked, suspended, placed
on probation, or otherwise subject to any type of disciplinary action?
ifyes, explainfullyinaseparatenotariZedstatement.

do you have any condition or impairment, including a history of alcohol or substance abuse that currently
interferes, or if left untreated may interfere, with your ability to practice in a competent and professional manner?
ifyes, explainfullyinaseparatenotariZedstatement

10. are you listed on any state or federal sexual offender registry?
if yes, explain fully on a separate notariZed statement.

pursuant to section 324.010 rsmo:

no

no

no

cHecK tHis box only if in all of tHe last 3 years: you Were not a missouri resident, you did not HaVe any
missouri income, and you are not subJect to any type of missouri income tax.

False statements are subject to criminal penalties and/or license discipline.

if you have any questions regarding taxes contact the department of revenue at 573-751-7200 or e-mail income@dor.mo.gov.

mo 375-0239 (12-13)

note: **you must provide your social security number pursuant to state and federal law.**
if you fail or refuse to provide your social security number, we will consider your initial application or renewal application incomplete and
return it to you. continued failure or refusal to provide your social security number is grounds for denial of your application and could result
in the imposition of late fees, administrative revocation of your license, a lapsed license or disciplinary action against your license.

section V - affidaVit (to be notariZed by a notary public)

i am aware that all documents needed for licensure by examination must be received in the board office before my original license can be
issued. i am also aware it is my obligation, pursuant to board regulations, to keep the board informed of my current name and address.

being duly sworn, i state that i am the person whose photograph is attached, and who is referred to in the foregoing application for
licensure as a registered professional nurse in the state of missouri; that the statements therein are strictly true in every respect; that
i have complied with all requirements of law; that i am of good moral character; and that i have read and understood this affidavit.
mustbesignedinpresenceofnotary

stateof

subscribed and sWorn before me, this

notary public signature

day of

20
my commission
expires

applicant signature

county (or city of st. louis)

notary public embosser seal

use rubber stamp in clear area beloW.

notary public name (typed or printed)

section Vi - nursing program director endorsement

to be completed by the nurse administrator of the nursing program.

i verify that the person named in this application is the person Whose
photograph is attached.

attach
photograph
here

donotpaste
or staple

tobeacceptable the photograph must be 2 x 2 inches in

size, recent and shoW a clear
picture of your face.
please use clear tape

nurse administrator signature

school of nursing

program code

PLEASE AFFIX
SCHOOL SEAL

data provided below is voluntary and is not required in order to submit an application for licensure. this data will assist the department in
nurse demographics. please print in blacK inK.
gender

female

race/ethnic group

male

caucasian (White)
asian/pacific islander

nationality

american

language

english

citizenship

united states

mo 375-0239 (12-13)

african-american
hispanic
american indian/alasKan native
other (if other please indicate) _____________________________________________________
foreign (please indicate) _________________________________________________________

foreign (please indicate) _________________________________________________________

foreign (please indicate) _________________________________________________________