Registered Nurse Expired/Inactive Reactivation Application
Important social security number information
You are required by state and federal law to provide a social security number with your application. If you do
not have a social security number, please read, complete, and return the SSN Verification Form with your
application.
This disclosure is mandatory, based on section 466(a)(13) of the Social Security Act [42 U.S.C. 666(a)(13)],
and will be used under the State’s child support enforcement program to locate individuals for the purposes of
establishing paternity and establishing, modifying, and enforcing support obligations.
A U.S. Individual Taxpayer Identi ication Number (ITIN) or a Canadian Social Insurance Number (SIN)
cannot be substituted for a social security number.
Mail your application and supporting documents
DOH 669-404 May 2023
Mail your application with your
check or money order payable to:
Dept of Health
PO Box 1099
Olympia, WA 98507-1099
RCW/WAC links
Uniform Disciplinary Act, RCW 18.130
Administrative Procedure Act, RCW 34.05
Administrative Procedures and Requirements, WAC 246-12
Nursing Laws, RCW 18.79
Nursing Rules, WAC 246-840
How To Return To Active Status From Expired Status, WAC 246-12-040
Send supporting documents not
mailed with your application to:
Nursing Commission
111 Israel Road SE
Mail Stop 47864
Olympia, WA 98504
Contact us
Phone: 360-236-4703
E-mail:
NurseLicensing@doh.wa.gov
Additional Important Information
1. It is your responsibility to renew your RN license annually up to 90 days prior to your birthday regardless if
you receive your renewal notice.
2. If you are renewing an expired credential and your license is reactivated prior to your next birthday, you
will still be responsible for paying your renewal fees of the upcoming renewal cycle.
3. Name change requirement: If you applied for a nurse or healthcare license in Washington state through the
Washington State Department of Health and have since changed your name, we require a copy of
the legal name change document submitted with your application. ( such as a marriage certificate, divorce
decree, or other court documents)
4. If your RN license has been expired for more than 3 years and you do not have an active license in another
U.S. state, you will need to complete a commission approved refresher program. We will issue an LEA for
you to complete the clinical portion of your refresher program after your program has notified us of
completion of the theory portion.
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Will documents be received in another name? Yes No
If yes, list name(s):
DOH 669-411 May 2023
Page 1 of 4
Date
Stamp
Here
For Ocial Use Only
Registered Nurse Reactivation Application
Revenue 0258010000
For Oce Use Only
Review for: FBI NPDB/NURSYS WSP PDQ NOD
Approved per policy A21.07 delegated decision making for selected license applications
Forward to CMT Approved by CMT Denied by CMT
Proceed with licensing process _____________________________________ _____________________
Signature
Date
If we do not receive all required documentation within 30 days your application may be closed as
incomplete resulting in you having to reapply and pay the application fee again.
Select if the following applies: Spouse or Registered Domestic Partner of Military Personnel
1. Demographic Information
Male
Female
Other
Social Security Number (SSN) :
(If you do not have a SSN, see instructions)
Name (First, Middle, Last):
Birth date: E-mail address:
Address:
City:
County:ZIP code:
Country:
Note: The mailing and e-mail addresses you provide will be your addresses of record. It is your responsibility to
maintain current contact information on le with the Nursing Commission.
Have you ever been known under any other name(s)? Yes No
If yes, list name(s):
Phone number:
State:
Select if needing to complete a refresher course: Limited Education Authorization
DOH 669-411 May 2023
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2. Personal Data Questions Yes No
1. Do you have a medical condition which impairs or limits your ability to practice your profession with
reasonable skill and safety? ...........................................................................................................................
If you answered yes to question 1, explain:
a. How your treatment has reduced or eliminated the limitations caused by your medical condition.
b. How your field of practice, the setting or manner of practice has reduced or eliminated the
limitations caused by your medical condition.
Note: If you answered “Yes” to question 1, the Nursing Commission will assess the nature, severity, and
the duration of the risks associated with the ongoing medical condition and the ongoing treatment
to determine whether your license should be restricted, conditions imposed, or no license issued.
The Nursing Commission may require you to undergo one or more mental, physical or
psychological examination(s). This would be at your own expense. By submitting this application,
you give consent to such an examination(s). You also agree the examination report(s) may be
provided to the Nursing Commission. You waive all claims based on condentiality or privileged
communication. If you do not submit to a required examination(s) or provide the report(s) to the
Nursing Commission, your application may be denied.
2. Do you currently use chemical substance(s) which impair or limit your ability to practice your
profession with reasonable skill and safety? .................................................................................................
“Currently” means within the past two years.
“Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally.
3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or
frotteurism? ...................................................................................................................................................
4.
Are you currently engaged in the illegal use of controlled substances? ....................................................
“Currently” means within the past two years.
“Illegal use of controlled substances” is the use of controlled substances (e.g., heroin, cocaine) not
obtained legally or taken according to the directions of a licensed health care practitioner.
5. Have you ever:
a. Been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a
sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? .........................
b. Been charged with a crime and are currently facing potential prosecution in any state or
jurisdiction? ........................................................................................................................................
c. Been made aware that you are a current suspect or under investigation in any state or
jurisdiction that has not yet been completely resolved? .....................................................................
Note: If you answer “Yes” to any of the remaining questions, provide an explanation and certied
copies of all judgments, decisions, orders, agreements and surrenders. If you do not provide the
documents, your application is incomplete and will not be considered. To protect the public, the
department considers criminal history. A criminal history may not automatically bar you from
obtaining a credential. However, failure to report criminal history may result in extra cost to you
and the application may be delayed or denied. The department does criminal background checks
on all applicants.
DOH 669-411 May 2023
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I currently hold an “ACTIVE” Registered Nurse License in (List One State): ________________________________
3. Active License
4. Work History
Currently Working as an RN in another state or jurisdiction.
Not currently working as an RN (less than 3 years)
5. Washington State License Number
Please enter your Washington State RN license number: RN.RN. ____________________________________
6. Disciplinary Action Attestation
I certify no action has been taken by any state or federal jurisdiction or hospital, which would prevent or restrict my
right to practice my profession.
I further certify I have not voluntarily given up any credential or privilege or have not been
restricted in the practice of my profession in lieu of or to avoid formal action.
Applicant’s Initials
Not currently working as an RN (more than 3 years
and is enrolled in an approved refresher program)
2. Personal Data Questions (cont.) Yes No
6. Are you under current investigation, currently charged, or have you ever been found in any civil,
administrative, or criminal proceeding to have:
a. Possessed, used, prescribed for use, or distributed controlled substances or legend drugs in any
way other than for legitimate or therapeutic purposes? .....................................................................
b. Diverted controlled substances or legend drugs? ...............................................................................
c. Violated any drug law? ......................................................................................................................
d. Prescribed controlled substances for yourself? ..................................................................................
7.
Have you ever
:
a. Been found in any proceeding to have violated any state or federal law or rule regulating the
practice of a health care profession? .....................................................................................................
b. Been charged with or accused of violating any state or federal law or rule regulating the practice of
a health care profession? .......................................................................................................................
c. Been made aware that you are under current investigation in any state or jurisdiction for violating
any state or federal law or rule regulating the practice of a health care profession? ............................
11. Have you ever been disqualified from working with vulnerable persons by the Department of Social
and Health Services (DSHS)? ...................................................................................................................
8. Have you ever had any license, certificate, registration, or other privilege to practice a health care
profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? .................
9. Have you ever surrendered a credential like those listed in number 8, in connection with or to avoid
action by a state, federal, or foreign authority? .........................................................................................
10. Have you ever been named in any civil suit or suffered any civil judgment for incompetence,
negligence, or malpractice in connection with the practice of a health care profession? ........................
DOH 669-411 May 2023
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8. Applicant’s Attestation
I, ____________________________________ , declare under penalty of perjury under the laws of the state of
(Print applicant name clearly)
Washington that the following is true and correct:
• I am the person described and identied in this application.
• I have read RCW 18.130.170 and RCW 18.130.180 of the Uniform Disciplinary Act.
• I have answered all questions truthfully and completely.
• The documentation provided in support of my application is accurate to the best of my knowledge.
• I have read all laws and rules related to my profession.
I understand the Nursing Commission may require more information before deciding on my application. The Nursing
Commission may independently check conviction records with state or federal databases.
I authorize the release of any les or records the department requires to process this application. This
includes information from all hospitals, educational or other organizations, my references, and past and present
employers and business and professional associates. It also includes information from federal, state, local or foreign
government agencies.
I understand that I must inform the Nursing Commission of any past, current or future criminal charges or
convictions. I will also inform the Nursing Commission of any physical or mental conditions that jeopardize my ability
to provide quality health care. If requested, I will authorize my health providers to release to the Nursing Commission
information on my health, including mental health and any substance abuse treatment.
By:__________________________________________________ Dated ___________________________
(Original signature of applicant) (mm/dd/yyyy)
7. Fee Attestation
I have read the application instructions on the Nursing Commission's website. I attest to applying
for the correct nursing credential type. This includes the correct designation (NP, CNS, CRNA,
or CNM) if applying for an ARNP credential. I understand that all application fees related to this
application are nonrefundable per WAC 246-12-340.
Applicant’s Initials
