If you apply for a professional license – in this case a nursing license – on the Georgia Secretary of State’s Website, you will see this online application.

“By submitting this online application, it is my intent to conduct this transaction with the Georgia Board of Examiners of Licensed Practical Nurses using electronic means and that the submission of the application means that I affirm that the answers to the following questions and statements made on this application are true and correct to the best of my knowledge and belief. I affirm this with the understanding that any omissions, inaccuracies or failure to make full disclosures may be deemed sufficient reason to deny, suspend or revoke a license issued by the Georgia Board of Examiners of Licensed Practical Nurses.

I further state that I have read the current state laws and board rules and regulations of the Georgia Board of Examiners of Licensed Practical Nurses governing the practice of nursing in the State of Georgia. I swear or affirm that I understand these laws and rules. I agree to abide by these laws and rules. I also agree to abide by future laws and rules that may be established by the Georgia Board of Examiners of Licensed Practical Nurses. I understand that violation of the laws and rules governing the practice of pharmacy may result in disciplinary action being taken against me which may include denial, suspension or revocation of my license to practice optometry.
By submitting this application, it is my intent to electronically sign this application.

Question

Answer
Are you a U.S. citizen?

Have you ever been arrested, convicted of a felony or misdemeanor (other than minor traffic violation) or entered a plea of guilty, nolo contendere or under the “First Offender Act,” or been sanctioned by another board or agency? DUI and DWI are not minor traffic violations.

If you answered “Yes” to the question regarding court convictions, you must submit to the Board the following: a) a copy of conviction/sentencing document(s) from the Court before which you were convicted and sentenced, signed by the presiding judge, and showing said conviction and sentence; AND, if applicable, b) a statement (on official letterhead) from your probation / parole officer regarding your current status/completion of any probation / parole. Your application will not be processed until this information is received and reviewed by the Board.

Have you taken the PN licensing examination in this or any other state? If “Yes,” please submit a list of states and dates of examination to the board.

Has any state licensing board revoked, suspended, refused renewal or otherwise disciplined your license or have you ever voluntarily surrendered your license? If yes, please provide a letter of explanation along with copies of all board orders to the Board office.

Have you failed to renew a license, certification or registration during an investigation against you by a licensing board or other agency?

Name: Addresses:

Licensee Address:

Street:
City:
State: Zip Code:

Email:
Phone:
Fax:

License Address:

Street:
City:
State:
Zip Code:
Email:
Phone:
Fax:

License Being Applied For:

License Number: Pending Profession: Licensed Practical Nurse License Type: Licensed Practical Nurse License Status: Pending
Issued: Expires:

Question Answers Summary

Are you a U.S. citizen?
Have you ever been arrested, convicted of a felony or misdemeanor (other than minor traffic violation) or entered a plea of guilty, nolo contendere or under the “First Offender Act,” or been sanctioned by another board or agency? DUI and DWI are not minor traffic violations.

If you answered “Yes” to the question regarding court convictions, you must submit to the Board the following: a) a copy of conviction/sentencing document(s) from the Court before which you were convicted and sentenced, signed by the presiding judge, and showing said conviction and sentence; AND, if applicable, b) a statement (on official letterhead) from your probation / parole officer regarding your current status/completion of any probation / parole. Your application will not be processed until this information is received and reviewed by the Board.
Have you taken the PN licensing examination in this or any other state? If “Yes,” please submit a list of states and dates of examination to the board.
Has any state licensing board revoked, suspended, refused renewal or otherwise disciplined your license or have you ever voluntarily surrendered your license? If yes, please provide a letter of explanation along with copies of all board orders to the Board office.
Have you failed to renew a license, certification or registration during an investigation against you by a licensing board or other agency?

Click here to download and print the LPN Consent Form that must be submitted to the Board in order for your application to be considered.

“At this point please review the name, address, and license information. Go back to make corrections where required. If you are not a U.S. citizen but are a qualified alien under the federal Immigration and Naturalization Act, and are lawfully present in the United States, submit the form found here to the Board. When satisfied with your submissions, click the “Pay Fees and Submit” link below to submit your application. Application fees are nonrefundable.”

DOCUMENTATION TO DETERMINE QUALIFIED ALIEN STATUS
Please check the box which applies to your status. You must provide copies of the required documentation as an attachment to this form.
Alien Lawfully Admitted for Permanent Residence:
_____ – USCIS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”
_____ – Unexpired Temporary I-551 stamp in foreign passport or on USCIS Form I-94
Asylee:
_____ – USCIS Form I-94 annotated with stamp showing admission under §208 of the INA
_____ – USCIS Form I-688B (Employment Authorization Card) annotated “27a.12(a) (5)”
_____ – USCIS Form I-766 (Employment Authorization Document) annotated “A5”
_____ – Grant letter from the asylum office of USCIS
_____ – Order of an immigration judge granting asylum
Refugee:
_____ – USCIS Form I-94 annotated with stamp showing admission under §207 of the INA
_____ – USCIS Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (3)
_____ – USCIS Form I-766 (Employment Authorization Document) annotated “A3”
_____ – USCIS Form I-571 (Refugee Travel Document)
Alien Paroled Into the U.S. for at Least One Year:
_____ – USCIS Form I-94 with stamp showing admission for at least one year under §212(d) (5) of the INA
Alien Whose Deportation or Removal Was Withheld:
_____ – USCIS Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (10)
_____ – USCIS Form I-766 (Employment Authorization Document) annotated “A10”
_____ – Order from an immigration judge showing deportation withheld under §241 (b) (3) of the INA
Alien Granted Conditional Entry:
____ – USCIS Form I-94 with stamp showing admission under §203 (a) (7) of the INA
_____ – USCIS Form I-688B (Employment Authorization Card) annotated “274a.12 (1) (3)
_____ – USCIS Form I-766 (Employment Authorization Document) annotated “A3”
_____ – SEVIS Form I-20 validated by the student’s school for work at a particular employer for
Curriculum Practical Training
_____ – SEVIS Form I-20 validated by the student’s school for work at a particular employer
Plus a valid Employment Authorization Card noted for OPT-Optional Practical Training
Cuban/Haitian Entrant:
_____ – USCIS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code CU6, CU7, or CH6
_____ – Unexpired temporary I-551 stamp in foreign passport or on USCIS Form I-94 with the code CU6 or CU7
_____ – USCIS Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under §212(d) (5) of the INA
Alien Who Has Been Battered or Subjected to Extreme Cruelty:
_____ – USCIS petition and appropriate supporting documentation
___________________________________
Name of Applicant (please print clearly)
_____________________________________________________________________
Signature of Applicant Date Signed (MM/DD/YYYY

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