Indiana State Board of Nursing Candidate Submission Form

Indiana State Board of Nursing Candidate Submission Form

Indiana Code 25-23-1-3 instructs ISNA to recommend to the governor a list of qualified nurses for appointment to the board when a vacancy arises. Additionally, the Office of the Governor retains interested candidate information in anticipation of Board of Nursing vacancies. The ISNA Board will review your submission refer your submission to the Office of the Governor or provide an explanation of disproval back to you for consideration. ISNA Membership is not required. The data points below are required by the Governor's Office and not determined by ISNA.
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Gender:*
Race:*
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
I have lived in Indiana for the past ____ years:*
Political Affiliation*
Registered to Vote*

YesNo
Have you had any disciplanry action taken against your professional licensure in Indiana or any other state?*

NoYes
If Yes, please explain:
Do you currently serve on other boards or commissions?*

NoYes
If Yes, please explain:
Have you ever been a registered as a lobbyist?*

NoYes
If Yes, please explain:
Have you individually, through your employer, or through any entity you own, had contract or business relationship with the State?*

NoYes
If Yes, please explain:
Do you have any ongoing litigation against you?*

NoYes
If Yes, please explain:
Why do you want to serve on the Indiana State Board of Nursing?*
What skills or experiences will you bring to this seat?*
Which qualification(s) best describes your role?*

Consumer (non-nurse)RNLPNAPRNAPRN Prescriptive AuthorityFaculty Member with administrative leadership responsibilities, with at least one year of experience
The Coalition of Advanced Practice Nurses of Indiana (CAPNI) recommends CAPNI endorsement for APRN roles. If you are serving as an APRN, have you received endorsement to serve?

Yes, attached.I am not an APRN.I will email admin@capni.org for approval.
Please provide your resume or curriculum vitae.*

Cancelof
Consent, Waiver, and Release: The undersigned authorizes the release to the Indiana Governor’s Office, its staff, agents, and representatives, of records and reports requested by the Governor’s Office in the performance of limited background checks on individuals who desire to serve on boards, commissions, councils, and other similar instrumentalities of the State of Indiana, such as criminal, driving, and disciplinary histories. The undersigned waives and releases the Indiana Governor’s Office, its staff, employees, agents, and representatives (including the Indiana State Police and any other agency or person providing such information to the Governor’s Office), from any claims and/or liabilities arising in connection with the furnishing and/or use of such information concerning the undersigned.

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