WEST VIRGINIA STATE BOARD OF EXAMINERS FOR LICENSED PRACTICAL NURSES
2014 ANNUAL LICENSE RENEWAL APPLICATION
101 DEE DRIVE, SUITE 100, CHARLESTON, WV 25311-1688 
PHONE 304-558-3572 FAX 304-558-4367
TOLL FREE:1- 877- 558-5767; CHARLESTON AREA: 558-5767; EMAIL: lpn.board@wv.gov
Web Site: http://www.lpnboard.state.wv.us
YOUR LPN LICENSE EXPIRES JUNE 30, 2014. YOU MUST RENEW THE LICENSE TO CONTINUE WORKING AS AN LPN.
READ QUESTIONS CAREFULLY. ONLINE RENEWAL WILL BE AVAILABLE UNTIL MIDNIGHT JUNE 30, 2014. BE SURE THAT YOUR TRANSACTION IS PROCESSED SUCCESSFULLY TO ENSURE RENEWAL OF THE LICENSE. YOU MUST USE A CREDIT CARD FOR RENEWAL - NO DEBIT CARDS PLEASE!
Billing will be from the WV State Treasurer's Office
All transactions will be processed the next business day

Check spelling for errors or typos as information is transferred to the Board's database as entered
1. Last Name 
First Name 
Middle Initial
If you have changed your name, you cannot renew online. The Board requires a copy of the legal document for a name change which must be mailed with a paper renewal form. Print the form from the Board's website or contact the Board office.
SSN#(last 4)  


LPN License No 


(When providing your address, please do not use periods or punctuation marks)

2. Address 
City 
County 
State 
Zip

3. Marital Status

4. Licensure Status and Fee: 

5. Year of initial US licensure
 

6. Country of initial LPN licensure

7. Highest Level of Education 



8. Employment Status
9. IF UNEMPLOYED, PLEASE PROVIDE MAJOR REASON:

10. If employed in Nursing, Employment Location
If other please specify

11. Name of Current Employer - (Type none if not employed) 
Employer Address
City
State
Zip
County


12. WHICH POSITION TITLE BEST DESCRIBES YOUR PRIMARY POSITION?
If other:

13. Please identify the employment specialty that most closely corresponds to your nursing practice position

14. In how many positions are you currently employed as a nurse
15. Number of hours worked per week in primary (where you work the most hours) nursing position  
Number of weeks worked per year in primary nursing position  

16. DOES YOUR PRIMARY NURSING POSITION INVOLVE PROVIDING DIRECT PATIENT CARE SERVICES TO PATIENTS/FAMILIES?

17. HOW LONG DO YOU EXPECT TO STAY IN YOUR PRIMARY NURSING POSITION?

18. HOW MANY YEARS HAVE YOU BEEN IN YOUR CURRENT PRIMARY NURSING POSITION?

19. HOW LONG DO YOU EXPECT TO PROVIDE DIRECT PATIENT CARE?

20. IF YOU ARE PLANNING TO LEAVE YOUR CURRENT NURSING POSITION, FOR WHAT REASON WOULD YOU BE LEAVING?

21. IF YOU WORK AS A NURSE IN A SECOND JOB, HOW MANY HOURS PER WEEK DO YOU WORK IN THAT JOB?
22. LIST ALL STATES IN WHICH YOU HOLD AN ACTIVE LPN LICENSE Use state abbreviation. If more than one state use a single space only between them - no commas or other punctuation
23. LIST ALL STATES IN WHICH YOU CURRENTLY PRACTICE AS AN LPN Use state abbreviation. If more than one state use a single space only between them - no commas or other punctuation
24. Have you ever been convicted, pled guilty, or no contest to a felony or a misdemeanor which has not been previously reported to the Board?
If YES, you cannot renew online. You must complete a paper application and mail it to the Board with a written explanation and copy of the court documents.
25. Have you ever had disciplinary action or is action pending against you by any other licensing board which has not been previously reported to the Board?
If YES, you cannot renew online. You must complete a paper application and mail it to the Board with a written explanation and copy of the court documents.
26. Do you currently possess any condition which may in any way impair your ability to practice or otherwise alter your behavior as it relates to the practice of licensed practical nursing?
If yes, please explain
27. Do you have a child support obligation?
If yes, does the amount of any unpaid obligation equal or exceed the amount of child support payable for six months?
Are you subject of a child-support or paternity subpoena or warrant?

28. Do you own all or part of a businesss that operates within West Virginia?
If Yes list the FEIN
WV Code 21A-2-6(18) provides that a board may not issue or renew a license for you to engage in the practice of a profession if you are in dafault under either the unemployment compensation laws or the workers compensation laws, or under both laws of this State

29. Are you presently enrolled in an R.N. educational program?

If yes College
Expected date of graduation (mm/yyyy)

CONTINUING EDUCATION - CONTINUING EDUCATION AND EMPLOYMENT HOURS ARE REQUIRED TO RENEW THE LICENSE THIS YEAR. YOU ARE REQUIRED TO HAVE COMPLETED AT LEAST 24 CONTACT HOURS AND 400 HOURS OF LPN EMPLOYMENT BETWEEN THE DATES OF JULY 1, 2012 AND JUNE 30, 2014. IF NOT PREVIOUSLY REPORTED, AT LEAST 2 OF THESE CONTACT HOURS MUST BE IN END OF LIFE CARE INCLUDING PAIN MANAGEMENT.

SPECIFIC REQUIREMENTS - MUST SELECT ONE OF THE FOLLOWING: 


***ALL LICENSEES WHO ARE REQUIRED TO REPORT CE MUST REPORT AT LEAST 3 CONTACT HOURS IN THE TOPIC OF SUBSTANCE ABUSE PURSUANT TO LEGISLATION PASSED DURING THE 2012 LEGISLATIVE SESSION.***


COLLEGE COURSES RELEVANT TO NURSING COMPLETED IN AN ACCREDITED INSTITUTION OF HIGHER LEARNING CAN APPLY, BUT MUST HAVE BEEN COMPLETED SINCE JULY 1, 2012. EACH SEMESTER HOUR OF COLLEGE CREDIT RECEIVED EQUALS 15 CONTACT HOURS OF CE. EACH QUARTER HOUR OF COLLEGE CREDIT EQUALS 10 CONTACT HOURS OF CE.

FALSIFICATION OF INFORMATION REGARDING CONTINUING COMPETENCE REQUIREMENTS IS GROUNDS FOR DISCIPLINARY ACTION AGAINST YOUR LPN LICENSE. RANDOM AUDITS VERIFYING COMPLETION OF CONTINUING COMPETENCE REQUIREMENTS ARE CONDUCTED BY THE BOARD.

IF YOU ALLOW YOUR LICENSE TO LAPSE OR PLACE YOUR LICENSE ON INACTIVE, YOU ARE REQUIRED TO COMPLETE THE REINSTATEMENT PROCESS TO ACTIVATE YOUR LPN LICENSE. THE APPLICATION FOR REINSTATEMENT IS AVAILABLE ON THE BOARD'S WEBSITE, OR YOU MAY CALL THE BOARD OFFICE FOR ASSISTANCE.


READ BEFORE AGREEING
CERTIFICATION AND RELEASE OF RECORDS STATEMENT: By checking 'I AGREE' below, I hereby certify that I have answered all questions truthfully and am eligible for renewal of my license to practice as a licensed practical nurse. I understand that supplying false information on this renewal application is grounds for disciplinary action including, but not limited to immediate revocation or suspension of the license. FURTHER: I authorize the release of all documents compiled by any law enforcement agency pertaining to me, to the Board upon the request of the Board or its agent. Said release includes records in existence as of this date, as well as those compiled at any time in the future. IF YOU HAVE BEEN CONVICTED OF A CRIME OR HAD DISCIPLINARY ACTION OR ACTION IS PENDING IN ANOTHER STATE WHICH HAS NOT PREVEVIOUSLY BEEN REPORTED TO THE BOARD OR POSSESS ANY CONDITION WHICH MAY IMPAIR YOUR ABILITY TO PRACTICE ATTACH APPROPRIATE LEGAL DOCUMENTS AND A WRITTEN EXPLANATION:

TO INSURE COMPLIANCE WITH FEDERAL LAW, THE BOARD IS OBLIGATED TO INFORM EACH LICENSEE THAT REPORTING OF THE SOCIAL SECURITY NUMBER IS MANDATORY SO THAT THIS BOARD CAN COMPLY WITH THE REQUIREMENT OF THE HEALTHCARE INTEGRITY AND PROTECTION DATA BANK. IN THE EVENT THAT THE BOARD IS REQUIRED TO SUBMIT A REPORT ABOUT A LICENSEE TO THE DATA BANK, IT MUST REPORT THAT INDIVIDUAL'S SOCIAL SECURITY NUMBER.
Check here if you agree to the terms above