9960 Mayland Drive
Suite 300
Perimeter Center
Henrico, Virginia 23233
(804) 367-4515 www.dhp.virginia.gov/nursing
CHECKLIST INSTRUCTIONS FOR REINSTATEMENT
APPLICATION: CLINICAL NURSE SPECIALIST
REGISTRATION
Check One:
Reinstatement Reinstatement After Discipline
Pursuant to Virginia nursing regulation 18 VAC 90-19-210 a Clinical Nurse Specialist whose registration has lapsed for more
than two (2) years or has been revoked or suspended shall apply for reinstatement.
Note: Virginia is a compact state under the Enhanced Nurse Licensure Compact (eNLC). If your primary state of residence
(PSOR) is a compact state, you must apply for licensure in your PSOR (compact state). If your primary state of residence is
Virginia or a non-compact state, and your Virginia license has been expired for more than two years, you may apply in
Virginia for reinstatement. Indicate on the application your primary state of residence. For current information on the NLC
go to: https://www.ncsbn.org/nurse-licensure-compact.htm.
REQUIREMENTS are listed below to submit an application for Reinstatement of Clinical Nurse Specialist
Registration. Check applicable COMPLETED items that are included with your application:
Completed Reinstatement application and required fee ($125): Fees must be paid by check or money order,
made payable to The Treasurer of Virginia. An application will not be reviewed or considered until payment is
submitted. Fees are non-refundable.
Current license as a registered nurse in Virginia or a current multistate licensure privilege as a registered
nurse: must meet this requirement to be eligible to reinstate a clinical nurse specialist registration.
Current national clinical nurse specialist certification in accordance with Virginia Code § 54.1-3018.1.
ADDITIONAL INFORMATION:
• The VBON may request additional evidence that the nurse is prepared to resume practice in a safe, competent
manner.
• Nursing laws and regulations may be obtained at www.dhp.virginia.gov/nursing.
• Documents submitted with the application are property of the Board and cannot be returned.
THIS COMPLETED INSTRUCTION CHECKLIST MUST BE SUBMITTED WITH APPLICATION
Revised: 5/1/18
Page 2 of 4
9960 Mayland Drive
Suite 300
Perimeter Center
Henrico, Virginia 23233
(804) 367-4515 www.dhp.virginia.gov/nursing
APPLICATION – REINSTATEMENT OF CLINICAL NURSE SPECIALIST REGISTRATION
FOR OFFICE USE ONLY (FINANCE DIVISION)
FOR OFFICE USE ONLY (VBON STAFF)
Fee paid:
$125
Applicant ID#:
Receipt #:
Approved:
Date:
I hereby make application to reinstate my registration as a Clinical Nurse Specialist in the Commonwealth of Virginia. The following
information in support of my application is submitted with a check or money order made payable to the Treasurer of Virginia in the
amount of $125. The fees are non-refundable.
Disclosure of Addresses
Pursuant to Virginia Code § 54.1-2400.02
addresses of licensees are made available to the public. Normally, the Address of Record is
the publicly disclosed address. If you do not want your Address of Record to be made public, you may provide a second, publicly
disclosable address (e.g. work or practice address). If you would like your Address of Record to be publicly available complete both
sections with same address.
Disclosure of Social Security or DMV Control Numbers
Pursuant to Virginia Code § 54.1-116 (A)
, you are required to submit your social security number or your control number issued by the
Virginia Department of Motor Vehicles. If you fail to do so, the processing of your application will be suspended and fees will not be
refunded. This number will be used by the Department of Health Professions for identification and will not be disclosed for other
purposes except as provided for by law. Federal and state law requires that this number be shared with other agencies for child
support enforcement activities.
1. APPLICANT INFORMATION - provide the information
requested below and on all pages. (Print or Type)
Use full name, not initials.
Applicant Type (Check One):
Reinstatement Reinstatement After Discipline
Name: Last
First
Middle/Maiden
Suffix
Address of Record (Mailing Address)
City
State
Zip
Telephone Number
Publicly Disclosable Address
City
State
Zip
Telephone Number
Email Address:
Full Name at Time of Initial Licensure/Registration:
Date of Birth:
___ ___ / ___ ___ / ___ ___ ___ ___
Social Security Number or Virginia DMV Control Number*:
Virginia CNS Registration Number:
DECLARATION OF PRIMARY STATE OF RESIDENCE
I declare that the state of: is my Primary State of Residence and that such constitutes my permanent
and principal home for legal purposes. (*If not VA, refer to Compact info on the Instruction page).
Page 3 of 4
CNS Reinstatement Application
2. EMPLOYMENT INFORMATION
If employed, list your current
Employer and job title:
Employer:
Job Title (position title):
3. LICENSURE HISTORY/QUESTIONS (pertains to any license or certificate ever issued to applicant)
CURRENT LICENSE INFORMATION
I hold an ACTIVE (Check Applicable Items):
Virginia RN License #:
Expiration Date:
Compact Multi-State RN License #:
State:
Expiration Date:
Answer YES or NO to EACH of the following:
1. Have you ever had disciplinary action taken against any license/registration/certificate to practice in a state or against your multi-
state privilege to practice in a state? YES NO
2. Have you ever voluntarily surrendered any license/registration/certificate or multi-state privilege issued to you to avoid disciplinary
action? (Does not include allowing your license to expire or placing the license in inactive status.)
YES NO
3. Have you ever had any of the following disciplinary actions taken against your license/registration/certificate or multi-state privilege by
any licensing authority in any jurisdiction: placed on probation, suspended, revoked or otherwise disciplined? YES
NO
4. Have you ever applied for and been denied a license/registration/certificate or multi-state privilege in a health related field or
jurisdiction? YES
NO
5. Have you ever been the subject of an investigation by any licensing authority? YES NO
6. Have you ever been convicted, pled guilty to or pled Nolo Contendere to the violation of any federal, state or other statute or
ordinance constituting a felony or misdemeanor? (Including convictions for driving under the influence and reckless driving but
excluding other traffic violations)? *YES
NO *Information Previously provided
7. Within the past five (5) years, have you exhibited any conduct or behavior that could call into question your ability to practice in a
competent and professional manner? YES
NO
A. If YES, detail under Explanation section.
B. Within the past five (5) years, have you sought or been directed to seek treatment for your conduct or behavior?
YES NO
8. Within the past five (5) years, have you been disciplined by any entity? YES NO
A. If YES, detail under Explanation section and provide any associated orders or letter from entity.
B. Within the past five (5) years, have you sought or been directed to seek treatment for your conduct or behavior?
YES NO
9. Do you currently have any physical condition or impairment that affects or limits your ability to perform any of the obligations and
responsibilities of professional practice in a safe and competent manner? “Currently” means recently enough so that the condition
could reasonably have an impact on your ability to function as a practicing nurse.
YES NO
A. If YES, detail under Explanation section. (Note: The Board may request a letter from your current treatment provider addressing
your current condition and ability to safely practice. You may consider providing this documentation with your application, or
have your provider send this documentation directly to the Board).
Page 4 of 4
CNS Reinstatement Application
LICENSURE HISTORY/QUESTIONS CONTINUED
Answer YES or NO to EACH of the following:
10. Do you currently have any mental health condition or impairment that affects or limits your ability to perform any of the obligations and
responsibilities of professional practice in a safe and competent manner? “Currently” means recently enough so that the condition
could reasonably have an impact on your ability to function as a practicing nurse.
YES NO
A. If YES, detail under Explanation section. (Note: The Board may request a letter from your current treatment provider addressing
your current condition and ability to safely practice. You may consider providing this documentation with your application, or have
your provider send this documentation directly to the Board).
11. Do you currently have any condition or impairment related to alcohol or other substance use that affects or limits your ability to
perform any of the obligations and responsibilities of professional practice in a safe and competent manner? “Currently” means
recently enough so that the condition could reasonably have an impact on your ability to function as a practicing nurse.
YES NO
A. If YES, detail under Explanation section. (Note: The Board may request a letter from your current treatment provider addressing
your current condition and ability to safely practice. You may consider providing this documentation with your application, or have
your provider send this documentation directly to the Board).
12. Within the past five (5) years, have any conditions or restrictions been imposed upon you or your practice to avoid disciplinary action
by any entity? YES
NO
A. If YES, detail under Explanation section. (Note: The Board may request a copy of a current participation contract and summary
of compliance and/or documentation of successful completion. You may consider providing this documentation with your
application or have the program send this documentation directly to the Board).
4. MILITARY QUESTION(S):
13. Are you an active member or veteran of the U.S. military? YES NO
14. Are you the spouse of a member of the U.S. military who has been transferred to Virginia and who had to leave employment to
accompany your spouse to Virginia? YES NO
EXPLANATION(S) SECTION (If no information provided here: line through Section; or attach additional pages):
CERTIFICATION
I certify by entering my signature below, I am the person applying for licensure/registration and meet the qualifications required by Virginia
law and regulations. Further, I certify the information provided in this application has been personally provided and reviewed by me and
that statements made on the application are true and complete. I understand that providing false or misleading information as well as
omitting information in response to information requested in this application or as part of the application process is considered falsification
of the application and may be grounds for denial of or taking disciplinary action against an existing license.
Signature:
Date:
Revised: 5/1/18
