LPN Nurse Re-Entry Program Application

Applicant Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

License or Application Number Associated with your GBON License Application

Do you have an active Consent Order or Consent Agreement with the GBON?

Which of the following best describes your current status?

Please provide any learning accommodation requests that you have.

Learners will need to select a technical college from the list below to serve as their clinical study location. Re-entrants must be prepared to travel to clinical sites up to or greater than 60 miles from the participating technical college selected. Once a selection has been made, and the application has been submitted, no changes to the preferred participating Technical College will be accepted. Select your preferred location below.

Participating Technical College

I understand that in addition to the LPN Re-entry course fee, I am responsible for the costs incurred with meeting the requirements for attending the clinical study course including but not limited to background and/or drug screening, health screenings, immunization records, required vaccinations, malpractice insurance, ACEMAPP membership, CastleBranch membership, uniforms, and clinical monitoring software applications.

I acknowledge that the scheduling of the LPN Re-Entry Program Clinical Study Course is dependent upon completing the required forms and receiving approval from the Georgia Board of Nursing, including issuance of a temporary permit. The LPN Nurse Reentry Program does not control the review timeline or final determination of GBON.

I hereby attest I have read and understand the entirety of the information contained in this LPN Nurse Re-entry Program application and all accompanying documents. I understand that any omission, misrepresentation, or falsification of information may result in denial of my application, dismissal from the reentry program, disciplinary action, and/or referral to the appropriate licensing or regulatory authority. I further acknowledge that submission of this application does not guarantee acceptance into the LPN Nurse Re-entry Program. By typing my name in the box below, I acknowledge my responsibility to comply with all applicable laws, rules, regulations, and program requirements associated with nurse reentry and licensure.

Type your full name in the box below.

To be considered for the LPN Nurse Re-Entry Program at TCSG, applicants must provide the following documents with their applications.

PDF file of the Deficiency Letter received from the Georgia Board of Nursing (GBON) stating the requirements of participating in an approved LPN Nurse Re-Entry Program.
Evidence of current health care provider cardiopulmonary resuscitation (CPR) certification issued by the American Heart Association. Ensure this certification is valid for the full amount of time enrolled in the LPN Nurse Re-Entry Program (minimum of 6 future months).
PDF file of the Certificate of Completion of the Georgia Licensed Practical Nurse Jurisprudence Examination.

Please note: iPhone HEIC/HEIF files cannot be used as supporting documentation

Deficiency Letter Listing Re-Entry Requirements from Georgia Board of Nursing

Evidence of Current AHA Health Care Provider CPR Certification

Georgia Licensed Practical Nurse Jurisprudence Examination Certificate of Completion

LPN Nurse Re-Entry Program Application

Participating Technical College

Attestations