Convenient Licensing Intake Form

Please complete the following form. Fill out any sections that are not covered in your resume or other uploaded documents.

Contact Information
Name*

First NameMiddle NameLast NameSuffix
Maiden or Previous Name(s), If none please insert N/A*
Date of Change/ Reason for Change
Upload name change documentation, if applicable

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Mother's Maiden Name*
If applying for a Massachusetts APRN license please provide Father’s Full Name
If applying for a Massachusetts APRN license please provide Mother’s Full Name
Home Address*

Street Address

City

StateCounty

Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
what is your preferred address of record*

HomeOther
If you selected other, please provide your preferred address of record

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment Verification Contact *

Identifying Information
Birth Date*

MonthDayYear
Birth Date*

MonthDayYear
Date
Social Security Number *
Gender*

MaleFemale
Place of Birth - City, State, and Country*
Citizen status/ Naturalization Date (If Applicable) *
What is your Marital Status?*

U.S. Military Service
Have you served in the U.S Military?*

YesNo
Has your spouse served in the U.S Military?*

YesNO
Branch Type a labelRankType a label Date of Service from-to Type a label Discharge Status Type a label Discharge DateType a label

Education and Professional History
What is your profession? *

Registered NurseNurse PractitionerPhysician AssistantMD/ DO
If you are a Nurse Practitioner, do you have a compact Registered Nurse license?*

YESNON/A

Education information - Starting with elementary school, list in chronological order all schools, colleges and universities attended, whether completed or not.*

	Name	City/ State	Month/Year From-to	Major/ Degree
Elementary School
Middle School/Junior High School
High School
Post-High School Education
ADN
BSN
MSN
DNP
Post-Master’s Certificate
Other

Practice History- List in chronological order all professional experience. Explain any unaccounted for periods of time exceeding 30 days.*

	Name	City/ State	Month/ Year From-To	Position	# Of Hours Worked
1
2
3
4
5
6

Licensure History- List ALL nursing licenses, whether active, inactive, or lapsed.*

	State	Type	License/Cert Number	Issue Date	Expiration Date	Status
1
2
3
4
5
6
7
8
9
10
11
12
12
14
15
16
17
18
19
20

DEA Registration - List all of the states you hold a DEA registration in

	State	Registration #	Issue Date	Expiration Date
1
2
3
4

National Specialty Certification

	National Specialty Board	Specialty	Certification Date - Expiration
1
2
3
4

Pease provide your AANP/ ANCC portal credentials

User NamePassword

File Uploads
Please Upload Resume

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Please Upload National Certificates

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Please Upload all Licenses and DEA Certificates

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Please Upload Your ID

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Please upload proof of citizenship

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If you were educated outside of the US. Please upload your diploma

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Malpractice/ Adverse Actions- Please explain any affirmative answers.
Have any adverse actions ever been filed against you by any school, hospital or medical board?*

YESNO
Have you ever been named in a malpractice suit or claim, regardless of outcome?*

YESNO
Have you ever been arrested, charged or convicted of any violation of any local, state, or federal statute including DUI / DWI?*

YESNO
Are you currently a participant in an alternative to discipline, diversion, monitoring ,or a peer assistance program (this includes all confidential programs)?*

YESNO
Do you have an investigation or complaint pending on a medical or nursing license or a privilege to practice in any state, country, or province?*

YESNO
If you answered 'yes' to any of the above questions or have any other malpractice actions, please provide a brief explanation.

Supervising Physician- Provide the requested information for a supervising physician in each state that you are applying to that requires one.(AL, AR, CA, CT, DE, FL, GA, IL, IN, KS, KY, LA, MI, MS, MO, NE, NJ, NY, NC, NV, OH, OK, PA, SC, TN, TX, UT, VA, WV, WI).

	Name	State	License Number	Email/ Phone
1
2
3
4
5

Service Agreement
I, Name* (the undersigned), am hiring (Convenient Licensing) to assist me in applying for state nursing licensure, registrations, and credentials as specified below (the "Services") or as requested from time to time either verbally or in writing by myself, my employer, or representatives. I agree to provide you all information and documents required for you to perform the Services, whether directly or via my employer or representatives. I affirm such information is and will be accurate and complete and such documents will be true, correct, and complete copies. I am aware of, and remain responsible for, the deadlines and eligibility requirements for each license, registration, or credential for which I am applying with your assistance. I agree to pay any fees or other charges required or imposed by the licensing boards to file or process my applications for licensure, registration, or credentials, as well as any additional costs related to transcripts, verifications, shipping, or other supporting documentation necessary for the licensing process. I understand and agree that all payments made to Convenient Licensing are non-refundable. I acknowledge and agree that the subscription to Convenient Licensing is required until all licenses are issued. If the subscription is canceled, I understand that Convenient Licensing will no longer continue working on my license applications. I acknowledge you have no authority to grant or cause to be granted any licensure, registration, or credential and, therefore, you will not be liable to me or any other person regarding the final outcome of my applications for licensure, registration, or credentials. I further acknowledge that you make no guarantee of any timelines in which any license, registration, or credential will be granted. I acknowledge I have read and agree to the additional terms and conditions specified at https://convenientlicensing.com/privacy-policy-2.
Service Agreement Consent*

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Date

MonthDayYear
Date

Third-Party Authorization
I Name (the undersigned), authorize all third-party entities to release any information requested within one year of the date on this signed release, whether in written, verbal, or any other form, to Convenient Licensing. This release serves as an official statement to request any confidential documentation on my behalf regarding education degrees, licensing examination score reports, professional societies or board affiliations, state board licensing agencies, hospital staff records, or any other certifications on record with the aforementioned entities. I authorize and release all referenced entities to provide any requested documentation to Convenient Licensing, thereby releasing them from liability for providing such information. I further authorize Convenient Licensing to conduct any research or investigations necessary to comply with the rules and regulations of all facilities throughout the application process.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Third-Party Authorization Consent*

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Which state(s) would you like to be licensed in?*
Do you want prescriptive authority?*

YESNO

My Products

APN State License1-9 APN State Licenses $275 each 10-29 APN State Licenses $250 each 30+ APN State Licenses $225 each

$275.00 Select how many states you want licensure in
Item subtotal:$0.00

Single State RN LicenseThere is an additional $100 fee for each RN state license obtained with an APN license. Non- Compact RN States are:

$100.00 Quantity
Item subtotal:$0.00

Maintenance And Renewal SubscriptionWe offer support in maintaining and renewing existing licenses, DEA registrations, controlled substance registrations, board re-certifications, and tracking continuing education requirements. I'll keep you informed about upcoming renewals and handle the paperwork processing with the state board when the time comes. $250 per month.

$250.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Credit Card Authorization and Card-on-File Consent

I, the undersigned, hereby authorize Convenient Licensing to charge my credit card for payment of their services, including any applicable third-party licensing fees incurred on my behalf. I understand that these charges are subject to the same terms and conditions as if I were presenting my card in person. I confirm that I am the authorized cardholder and that all charges will be honored by my card issuer in accordance with the cardholder agreement.

I also authorize Convenient Licensing to securely store my credit card information on file and to charge this card for future licensing-related services, including but not limited to application fees, renewals, and fingerprinting costs, as they arise. I understand that I will receive a receipt for each transaction processed.

I understand that any payments made to Convenient Licensing are non-refundable once they have been used to cover third-party fees or services on my behalf. I further acknowledge that the service fee paid to Convenient Licensing is non-refundable once the license application process has begun, regardless of the outcome, as approval is determined solely by the licensing board.

Important: Due to platform limitations, I understand that I must provide my credit card information verbally to Convenient Licensing for secure processing. By signing this form, I consent to this method and authorize all charges as described above.
Credit Card Authorization and Card-on-File Consent*

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How Did You Hear About Us? (Referral Name or Source)
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Please complete the following form. Fill out any sections that are not covered in your resume or other uploaded documents.