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

MaleFemale

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 - You may leave fields that are addressed on your resume blank.
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
1
2
3
4
5
6
7
8

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
1
2
3
4
5
6

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

	State	Type	Issue Date	Expiration Date
1
2
3
4
5
6

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 you (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 that are the subject of the Services. 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. By signing below I agree to the above statement and terms and conditions.
Signature*

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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 via written, verbal or otherwise stated, 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 certification on record with any of the above-named entities.I authorize and release all referenced entities to provide any requested documentation to Convenient Licensing, releasing the liability to any entity providing such referenced information. I further authorize Convenient Licensing to conduct any research or investigations which are necessary to comply with the rules and regulations of all facilities throughout the application process.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Credit Card Authorization I the undersigned, hereby grant authorization to Convenient Licensing, to charge my credit card for the payment of their services and any third-party charges related to their services. I acknowledge and agree that these transactions will adhere to all conditions of sale, as if I were physically presenting my credit card in person. I certify that l am the authorized cardholder of the provided credit card, and I assure that the charges made on the credit card will be duly honored. Furthermore, I confirm my commitment to fulfill all obligations outlined in the cardholder agreement with the credit card issuer. I understand and accept that any funds I have paid to Convenient Licensing, whether via credit card or any other method, are non-refundable after they have been utilized to cover third-party charges associated with the services provided to me.
Cardholder Name

First NameLast Name
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Card Number
Expiration Date
Security Number (CCV)
Signature

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