Convenient Licensing Intake Form

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

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I agree to receive updates via text/SMS
Email
example@example.com
How would you like us to handle the email used for your license applications?
Employment Verification Contact

Birth Date

MonthDayYear
Birth Date

MonthDayYear
Date
Social Security Number
Social Security Number
Are you of Hispanic or Latino origin?
Gender
Place of Birth - City, State, and Country
Citizen status/ Naturalization Date (If Applicable)
What is your Marital Status?

Have you served in the U.S Military?
Has your spouse served in the U.S Military?
Branch Type a labelRankType a label Date of Service from-to Type a label Discharge Status Type a label Discharge DateType a label

What is your profession?
If you are a Nurse Practitioner, do you have a compact Registered Nurse license?
Do you have a National Provider Identifier (NPI)? If yes, please provide it.

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

Rows	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.

Rows	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.

Rows	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

Rows	State	Registration #	Issue Date	Expiration Date
1
2
3
4

National Specialty Certification

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

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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Have any adverse actions ever been filed against you by any school, hospital or medical board?
Have you ever been named in a malpractice suit or claim, regardless of outcome?
Have you ever been arrested, charged or convicted of any violation of any local, state, or federal statute including DUI / DWI?
Are you currently a participant in an alternative to discipline, diversion, monitoring ,or a peer assistance program (this includes all confidential programs)?
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?
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).

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

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

I, the undersigned, am hiring Convenient Licensing to assist me with state nursing licensure, renewals, registrations, credentials, DEA registrations, controlled substance registrations, application preparation, document organization, application tracking, and related licensing support services as requested by me, my employer, or my authorized representative.
I understand that Convenient Licensing provides administrative licensing support services. These services may include preparing applications, organizing required documents, tracking application progress, requesting supporting documentation, communicating with licensing boards or third-party entities, assisting with forms, and providing checklist or portal support.
I certify that all information, documents, explanations, forms, identification, employment history, education history, license history, certification history, criminal history, disciplinary history, and any other information I provide to Convenient Licensing are true, accurate, complete, and not misleading.
I understand that Convenient Licensing relies on the information I provide when assisting with applications, renewals, registrations, and credentials. I acknowledge that inaccurate, incomplete, false, omitted, or misleading information may result in application delays, denial, board investigation, disciplinary action, or other consequences.
I agree to promptly notify Convenient Licensing if any information I previously provided changes or if I discover that any information provided was incorrect or incomplete.
I agree to provide all information, documents, login information, signatures, payments, explanations, court records, certifications, verifications, transcripts, employment records, and any other materials required for Convenient Licensing to perform the requested services.
I understand that I remain responsible for meeting all deadlines, eligibility requirements, document requirements, payment requirements, and board-specific requirements for each license, registration, renewal, or credential for which I am applying.
I understand that I am responsible for reviewing all applications, forms, and documents before submission when Convenient Licensing requests my approval. By approving an application, form, or document, I confirm that I have reviewed it and that the information is accurate and complete to the best of my knowledge.
I understand that Convenient Licensing has no authority to grant, approve, issue, renew, reinstate, or guarantee any license, registration, credential, DEA registration, controlled substance registration, or certification. Final decisions are made solely by the applicable licensing board, government agency, certification agency, or third-party entity.
I understand that Convenient Licensing does not guarantee approval, processing timelines, board acceptance, eligibility, renewal, reinstatement, or any specific licensing outcome. I further understand that board delays, third-party delays, background check delays, fingerprinting delays, transcript delays, verification delays, rule changes, requests for additional information, or processing backlogs are outside the control of Convenient Licensing.
I understand that a licensing board, government agency, or third-party entity may request additional information, documents, payments, explanations, interviews, fingerprints, background checks, or other materials after an application is submitted. I remain responsible for providing any requested information in a timely and accurate manner.
I acknowledge that Convenient Licensing is not a law firm and does not provide legal advice, legal representation, legal opinions, or legal services. Convenient Licensing does not represent me before any licensing board, government agency, court, investigator, disciplinary body, employer, or legal proceeding.
If my application involves criminal history, disciplinary action, license denial, license suspension, license revocation, investigation, impairment concerns, malpractice issues, immigration concerns, or any other legal matter, I understand that I may need to consult with an attorney. I understand that Convenient Licensing cannot advise me on how to answer legal questions or how a board may interpret my history.
I authorize Convenient Licensing to communicate with me by phone, text message, email, secure form, customer portal, or other electronic communication methods regarding my services. I understand that communication may include requests for documents, application updates, payment requests, board requests, reminders, service updates, portal notifications, and other licensing-related matters.
I understand that I am responsible for monitoring my email, phone, text messages, and customer portal for updates and requests. I agree to respond promptly. Failure to respond, provide documents, approve applications, pay required fees, or complete required steps may delay or prevent completion of my services.
I understand that if I fail to respond to requests, provide documents, approve applications, pay required fees, or communicate with Convenient Licensing for an extended period of time, my file may be paused, marked inactive, or closed. Additional fees may be required to reopen or resume services.
I understand and agree that all payments made to Convenient Licensing are non-refundable once work has begun. I also understand that third-party fees are non-refundable once paid on my behalf.
I acknowledge that I have read and agree to the additional terms and conditions specified at:
https://convenientlicensing.com/terms-of-service---privacy-policy
By signing below, I certify that I have read, understand, and agree to the terms above.
Service Agreement Consent
Date

MonthDayYear
Date

- Authorization to Release Information and Authorization to Assist
  
  I, the undersigned, authorize Convenient Licensing to assist me with licensing, renewal, registration, credentialing, application preparation, application tracking, document organization, and related administrative services as requested by me, my employer, or my authorized representative.
  I authorize Convenient Licensing to communicate with licensing boards, certification agencies, schools, employers, professional organizations, testing agencies, hospitals, credentialing departments, vendors, and other third-party entities as needed to assist with my licensing-related services.
  I authorize all third-party entities to release any information, records, documents, or verification details requested by Convenient Licensing. This includes, but is not limited to, information regarding education, degrees, transcripts, licensing examination scores, professional certifications, professional society or board affiliations, state board licensing records, hospital staff records, employment verification, disciplinary history, or any other records necessary to support my licensing, renewal, registration, or credentialing process.
  This release serves as my official authorization for Convenient Licensing to request, receive, review, and use information and documentation on my behalf for licensing-related purposes.
  I release all referenced entities from liability for providing information, records, or documentation to Convenient Licensing in connection with this authorization.
  I further authorize Convenient Licensing to conduct research, request clarification, follow up with boards or third-party entities, and take reasonable administrative steps necessary to assist with my applications and comply with applicable licensing requirements.
  I understand that this authorization does not give Convenient Licensing authority to make false statements, alter information, guarantee approval, or make final decisions on my behalf. I remain responsible for the accuracy and completeness of all information provided.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- Third-Party Authorization Consent

Credit Card Authorization and Card-on-File Consent

I, the undersigned, authorize Convenient Licensing to charge my credit card, debit card, or other payment method on file for payment of services, subscription fees, third-party licensing fees, and any other licensing-related expenses incurred on my behalf.

These charges may include, but are not limited to, service fees, state board application fees, license renewal fees, fingerprinting or background check fees, transcript fees, license verification fees, certification verification fees, DEA or controlled substance registration fees, mailing fees, notary fees, and any other third-party fees required for my licensing, renewal, registration, or credentialing process.

I confirm that I am the authorized cardholder or have permission to use the payment method provided. I understand that charges made under this authorization are subject to the same terms and conditions as if I were presenting my card in person.

I authorize Convenient Licensing to securely store my payment information on file through its payment processor and to charge this payment method for current and future licensing-related services and expenses as they arise. I understand that I will receive a receipt for each transaction processed.

I understand that third-party fees paid to licensing boards, government agencies, vendors, or other third-party entities are non-refundable once paid on my behalf. I further understand that service fees paid to Convenient Licensing are non-refundable once work has begun, regardless of whether my application, renewal, registration, credential, or license is approved, denied, delayed, withdrawn, abandoned, or otherwise not completed.

If I am enrolled in a subscription plan, I understand that my subscription must remain active for Convenient Licensing to continue providing services, tracking applications, communicating with boards, maintaining my portal, and assisting with pending licensing matters. If my payment is declined, canceled, unpaid, or if my subscription is discontinued, I understand that Convenient Licensing may pause or stop work until my account is current.

I understand that I remain responsible for all licensing-related fees, including any additional or increased fees requested by a licensing board, government agency, vendor, or third-party entity.

By signing this form, I authorize Convenient Licensing to process payments as described above.
Credit Card Authorization and Card-on-File Consent
How Did You Hear About Us? (Referral Name or Source)
Should be Empty:

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

Authorization to Release Information and Authorization to Assist