New Jersey Office of the Attorney General
Division of Consumer Aairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
www.NJConsumerAairs.gov/nursing
Instructions for Advanced Practice Nurse Certification in N.J.
Please read the following information carefully before completing an application for APN Certification.
If you previously held an APN certification in New Jersey, DO NOT complete this application. Please
complete the APN Reinstatement application.
1. Hold a current, active, and valid New Jersey license as a Registered Professional Nurse.
2. Please complete an application for APN Certification which is available on the Board’s website.
Answer ALL questions.
3. Sign the application in the presence of a notary public.
4. Attach a clear, full-face original passport-style photograph (2” x 2”) of your head and shoulders taken
within the past six months. Sign your name on the back of the picture. (Photocopies and selfies are not
acceptable.)
5. If you are a U.S.-born citizen, please submit a copy of your birth certificate or U.S. passport.
6. If you are a naturalized U.S. citizen, please submit a copy of your U.S. passport or certificate of
naturalization.
7. If you are a legal alien or other immigration status, please submit your USCIS immigration documents.
(Submit a copy of both the front and the back of your card.)
8. Submit proof of a legal name change (i.e., marriage license, divorce decree, court order) if your name
differs from that on your birth certificate.
9. Complete the Certification and Authorization form for a criminal history background check and submit
a check in the amount of $18.75 made payable to the State of New Jersey for a fingerprint archive
request.
10. Submit criminal history documents (if applicable).
11. Arrange to have a transcript from your master’s or doctoral program submitted directly to the Board.
12. Arrange to have proof of valid APN Certification within your specialty from your national
credentialing agency submitted directly to the Board.
13. Provide written verification of APN licensure in good standing from the state in which you were
originally licensed, or are currently licensed, and from every state in which you have ever been
licensed. The verification must be forwarded directly to the New Jersey Board of Nursing from the
applicable state board(s), if those state(s) are not listed on the NURSYS License Verification Form.
14. Submit proof of completion of six (6) contact hours of a pharmacology course related to C.D.S.
15. Submit Certificates of Completion of 30 continuing education credits in pharmacology, if you
graduated from your master’s/doctoral program more than five (5) years ago.
16. Submit the nonrefundable application fee in the amount of $100.00, made payable to the New Jersey
Board of Nursing, in the form of a check or money order.
17. You will receive a letter from the Board advising you of the initial certification fee due, either $80.00
or $160.00, based on the expiration date of your RN license.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Application for Advanced Practice Nurse Certication
(Do not submit this application unless and until you hold an active, valid New Jersey R.N. License.)
Date:_______________________________
Pleaseencloseanonrefundableapplicationlingfeeof$100.00intheformofacheckormoneyordermadeouttotheStateofNew
Jersey.(Applicantsshouldunderstand thatifthe feesarepaid withapersonal check,andthecheckis returnedbythe bankdueto
insufcientfunds,thenextstepinthelicensureorcerticationprocesswillbedelayeduntilthefeesarepaid.)Youwillalsoberequired
topayacerticationfeeatalaterdate.
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without their
consent. However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureof
yourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
tothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.
Informationthatyouprovideonthisapplication(includingyouraddressofrecord)maybesubjecttopublicdisclosureasrequiredby
theOpenPublicRecordsAct(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Dateofbirth:_________________________
MonthDayYear
Placeofbirth:________________________
CityState
Mr.
1. Name Mrs.________________________________________________________________ (_______________________)
Ms.
Lastname Firstname Middlename Maidenname
2. Address
Home:______________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
_____________________________________ ___________________________________
Telephonenumber(includeareacode) E-mailaddress
Business:____________________________________________________________________________________________
Nameofcompany Telephonenumber(includeareacode)
____________________________________________________________________________________________
Street City State ZIPcode County
Mailing: ____________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
Attachaclear,full-facepassport-
stylephotograph(2˝x2˝)ofyour
headandshoulders,takenwithin
thepastsixmonths.
A photo is required with each
application.
Donotuse staples to attachthe
photo.
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensureorcertication.
*Social Security Number: __________ -____________ - ___________
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7,60.8 and 60.9, the Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualiedaliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheoceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCISat:1-800-375-5283.
5. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensureorcertication.Furthermore,anyfalsecerticationoftheabovemaysubjectyoutoapenalty,including,butnotlimited
to,immediaterevocationorsuspensionoflicensureorcertication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
6. IllegalUseofControlledDangerousSubstances
Thequestionbelowpertainstotheillegaluseofcontrolleddangeroussubstances.Pleasereadthedenitionscarefully.Yourresponses
willbetreatedcondentiallyandretainedseparately.Pleasebeawarethatyouhavetherighttoelectnottoanswerthisquestionif
you have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you
may assert the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in
good faith. If you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on
theapplication.YourapplicationforlicensureorcerticationwillbeprocessedifyouclaimtheFifthAmendmentprivilegeagainst
self-incrimination. You should be aware, however, that you may later be directed by the Attorney General to answer a question that
youhaverefusedtoansweronthebasisontheFifthAmendment,providedthattheAttorneyGeneralrstgrantsyouimmunity
aordedbystatutorylaw,(N.J.S.A. 45:1-20).
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the previous
365 days, whichever is longer.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g. heroin
or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or not taken
in accordance with the directions of a licensed health care practitioner.
a. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances?(Asstatedabove,“currently”isdenedas
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
_____________________________________________________ ___________________________________
Applicant’s signature Date
7. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
8. Do you currently hold, or have you ever held, a professional license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a dierent name, please provide that name. ____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
9. Have you ever been disciplined or denied a professional license or certicate of any kind in New Jersey, any other state, the District of
Columbia or in any other jurisdiction? Yes No
10. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
11. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any agency
or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
12. Have you ever been named as a defendant in any litigation related to the practice of nursing or other professional practice in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
13. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons oense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.) Yes No
14. Have you ever been convicted of any crime or oense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
15. Are you aware of any investigation pending against a professional license or certicate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
16. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
17. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of nursing or other professional practice in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
If the answer to any of the above questions, numbers 9 through 17, is “Yes,” provide a complete explanation of the circumstances leading
to the action, and any supporting documentation, on separate sheets of paper.
18. Area of Clinical Specialty: ______________________________
The New Jersey Board of Nursing only recognizes certain categories of Advanced Practice Nurses.
19. New Jersey Registered Nurse license number: _______________________________
20. Are you certied or licensed for advanced nursing practice in another state(s)?
Yes No
If “Yes,” specify state(s) of certication or licensure. _________________________
You will need to obtain verication from these states. Refer to the enclosed Verication Request Form.
21. Entry-Level Nursing Education Completed:
Diploma Associate Degree Baccalaureate Degree
_________________________________________________ __________________________ _____________________
Name of nursing school Date graduated Credential
Entry-Level C.R.N.A. Education if not Master’s Degree, as appropriate
_________________________________________________ __________________________ _____________________
Name of program Date graduated Credential
22. Graduate Nursing Education Completed:
(Please have the ocial transcript(s) sent directly to the New Jersey Board of Nursing from the graduate nursing program(s).)
Master’s Degree in Nursing: ______________________________________ __________________________________
Area of specialty Date graduated
Name of Master’s in Nursing Program:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Street address City State ZIP code
Post-Master’s Nursing Certicate Program: __________________________ __________________________________
Area of specialty Date graduated
Name of Post-Master’s Certicate Program:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Street address City State ZIP code
23. Pharmacology Education Completed:
Graduate Level Three-Credit Course _______________________________
Date completed
30 Hours of Pharmacology* _____________________________________ __________________________________
Date completed No. of integrated pharmacy hours
(*If pharmacology was integrated into various courses (rather than a separate pharmacology course), please complete the enclosed
Completion of Integrated Pharmacology Form.)
Six (6) Contact Hours in pharmacology related to controlled dangerous substances, including pharmacologic therapy, and addiction
prevention and management.
(Please complete the enclosed form.)
24. National Clinical Specialty Certication: Yes No Cite 7.1(b)
(Please have the Certifying Agency submit verication of your certication directly to the Board.)
Name of Certifying Agency: _______________________________________________________________________________
Name(s) of certifying examination(s) that you passed/specialty: __________________________________________________
_______________________________________________________________________________________________________
Certication date: From ___________________ to __________________________
If you are not certied, please complete the following:
Name of Certifying Examination _____________________________
Name of Certifying Agency _________________________________
Scheduled test date: _______________________________________
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
Stateof:__________________________________________________
Countyof:________________________________________________
I, ________________________________________________ , inmaking thisapplicationto the New Jersey Board of Nursing for
licensureorcerticationundertheprovisionsofTitle45oftheGeneralStatutesofNewJerseyandtheRulesoftheNewJerseyBoardof
Nursing,swear(orafrm)thatIamtheapplicantandthatallinformationprovidedinconnectionwiththisapplicationistruetothebest
ofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmaybedeemedsufcient
todenylicensureorcerticationortowithholdrenewaloforsuspendorrevokealicenseorcerticateissuedbytheBoard.
Ifurtherswear(orafrm)thatIhavereadN.J.S.A.45:11-23etseq.,togetherwiththeRulesandRegulationsoftheNewJerseyBoard
ofNursing,N.J.A.C.13:37,andfullyunderstandthatinreceivinglicensureorcerticationfromtheBoard,Ibindmyselftobegoverned
bythem.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
thepurposeofverifyingmyqualicationsforlicensureorcertication.Ifurtherauthorizeallinstitutions,employers,agenciesandall
governmentalagenciesandinstrumentalities(local,state,federalorforeign)toreleaseanyinformation,lesorrecordsrequestedby
theBoard.
__________________________________________________
Signatureofapplicant
Swornandsubscribedtobeforemethis__________________
dayof ____________________________ ,______________
Month Year
__________________________________________________
NameofNotaryPublic(pleaseprint)
Afx Seal Here
__________________________________________________
SignatureofNotaryPublic
} ss.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
CertifiCAtion And AuthorizAtion form
for A CriminAl history BACkground CheCk
Directions:Answerallofthequestionsonthisform.
1. Name _________________________________________________________ ( ________________________)
Last First Middle MaidenName
2. Address___________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode
3. Dateofbirth____/____/____ Sex: Male Female
MonthDayYear
4. SocialSecuritynumber_________/_____ / ________
5. HaveyoucompletedthengerprintingprocessforanyBoard or Committee of the New Jersey Division of Consumer
Affairs
sinceNovember2003? Yes No
If“No,”youwillreceiveaseparatemailingfromtheBoardorCommitteeregardingthecriminalhistoryrecordbackground
checkprocess.Nopaymentisnecessaryasofnow.
If“Yes,”pleaseprovidethefollowinginformationandfollowtheinstructionsoutlinedbelow:
_______________________________________________ _______________________________________________
BoardorcommitteerequiringthengerprintingMonthandyearyouwerengerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certification by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background
checkconducted for the Departmentof Education, another stateagencyor another statedoesnot apply)you willnotbe
requiredtobengerprintedasecondtime.However,theDivisionmustperformacriminalhistorybackgroundcheckeachtime
youapplyforlicensureorcertication.The fee for this service is $18.75.Paymentshouldbemadeintheformofacheckor
moneyorderpayabletotheStateofNewJerseyandshouldaccompanyyourapplicationpacket.
6. Haveyoueverbeenarrestedand/orconvictedofacrimeoroffense?(Minortrafcoffensessuchasaparkingorspeeding
violationsneednotbelisted.) Yes No
Every such conviction on record must be disclosed. Atruecopyofeverypolicereport,judgmentofconviction,sentencing
orderandterminationofprobationorder,ifapplicable,must besubmittedwiththisform.Anydocuments(includingemployer
orsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust besubmitted
withthisform.Failure to follow these instructions may result in the denial of an initial application.
Note: Copiesofjudgments,sentencingandterminationofprobationordersmaybeobtainedfromtheclerkofthecounty
wherethoseorders,disposingoftheconviction,wereissuedandled.
Your continuing responsibility to disclose convictions of crimes or offenses:Youmust notifytheBoardorCommittee
withinve(5)businessdaysifyouareconvictedofanycrimesoroffensesafterthisformhasbeencompleted.
Continuationonthereverseside➨
Mr.
Mrs.
Ms.
BoardorCommittee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
DualLicense
LicenseType1
________________________
Applicant’sNumber
________________________
LicenseType2
________________________
Applicant’sNumber
________________________
APN
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
applicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefull
disclosuresmaybedeemedsufcienttodenycerticationorlicensureortowithholdrenewaloforsuspendorrevokeacerticate
orlicenseissuedbytheBoardorCommittee.
I
voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying myqualications for certication or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requestedbytheBoardorCommittee.
I
certifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymeare
willfullyfalse,Iamsubjecttopunishment.
_________________________________
__________________________________________________________
Signatureofapplicant
Date
Rev.1/2/19
Pharmacology Continuing Education Compliance Report Form
Name:_________________________________________________________R.N.LicenseNumber:_______________________
A.P.N.Specialty/Category:______________________________________________

I certify that the foregoing statements made by me are true to the best of my knowledge. I am aware that if
any of the foregoing statements made by me are willfully false, I am subject to punishment, including but not
limited to suspension or revocation of a license and/or certication under N.J.S.A. 45:1-21.
Signature: ___________________________________________________________
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Title of Program
Attach copies of the certicates*
Date
Program Provider
Contact
Hours
1 contact hour = 50 minutes
1 C.M.E./1 A.M.A. = 60 minutes = 1.2 contact hours
A total of 30 contact hours is required.
Total
_______
*Attach a copy of the program certicate of completion/attendance (usually one page) for each listing noted
above to add up to 30 contact hours.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Advanced Practice Nurse Certication Verication Request:
Certication of Advanced Nursing Practice
Directions:CompleteonlythetopportionofthislicensevericationformandforwardittotheBoardofNursinginthestate(s)in
whichyouareorhavebeenlicensed.Theboard(s)shouldcompletetheformandreturnittotheNewJerseyBoardofNursing.Note:
Beadvisedthattheboard(s)completingtheformmaychargeafeeforlicenseverication.Pleasecalltheboard(s)tocheckonfeesfor
licensevericationpriortosubmittingthisform.
Applicantname:___________________________________________________________________________
Firstname Middlename Lastname Maidenname,ifapplicable
Currentaddress:____________________________________________________________________________
Street City State ZIPcode
This section is to be completed by the State Board of Nursing.
Iherebycertifythat_______________________________________________ wasissuedcertication/licensure
Name
asa________________________________________________________________________________________
ClinicalSpecialty
(Checkone): NursePractitioner ClinicalNurseSpecialist
intheStateof__________________________________________________ on___________________________ .
Date
Thiscertication/licensureexpireson_______________________________ .
Date
Hasanydisciplinaryactionbeentakenagainstanylicenseorcerticationissuedtothisnursetopracticenursing?
(Checkone): Yes No
I
f “Yes,” pleaseexplain:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Icertifythatthestatementscontainedhereinaretruetothebestofmybelief,
andIrecommendthisnursefor
advancednursingpracticecerticationintheStateofNewJersey.
__________________________________________
ExecutiveOfcer
__________________________________________
NewJerseyBoardofNursing
__________________________________________
Date
Return to: New Jersey Board of Nursing, P.O. Box 45010, Newark, N.J. 07101
Ofcial
Seal