Board Info

CERTIFICATE OF LICENSURE (SUITABLE FOR FRAMING)

• Certificate of Licensure/Registration Order Form 

CREDENTIALS/LICENSURE
For your convenience, application forms are provided below for specific licensure methods.  These forms include the instructions and attachments.

Application Forms​

• SANE Credential Application Form 

Application Request Forms*
*The applications in this section require an additional fee when the application is submitted via paper. There is no additional fee if these forms are submitted electronically. Please fill out and submit the request form along with the additional fee, or visit the Online Services page if you wish to submit electronically.

• Paper Application Request Form - RN & APRN or APRN Only Licensure
• Paper Application Request Form - Examination 
• Paper Application Request Form - Endorsement
• Paper Application Request Form - Reinstatement
• Paper Application Request Form - Retired Status
• Paper Application Request Form - Licensure Renewal
  If you wish to renew using a paper application, you must send in this request form by October 15.

Other Licensure Forms

• Licensed Nurse Address/Email Change Form 
• Criminal Background Request Form (CourtNet)
• Licensed Nurse Name Change Form
• NCLEX Special Accommodations Request Form 
• NurSys Licensure Verification
• Verification of Employment - Outside of Kentucky (Attachment 1) 
• Verification of Original Licensure (Attachment 2) 
• Verification of Licensure to an Entity Other than a Board of Nursing Request Form 

APRN Prescriptive Authority Forms

Non Scheduled legend Drug Forms

• Common Collaborative Agreement Form - CAPA-NS (required Collaborative Agreement form by KY Law for Prescribing Non-Scheduled Legend Drugs)
• KBN Notification of CAPA-NS  
• KBN Notification to Discontinue CAPA-NS After Four Years  
• Rescission of a Collaborative Agreement for the Prescriptive Authority for Non-Scheduled Legend Drugs (CAPA -NS) Form

Controlled Substance Forms

• Sample CAPA- CS form that meets these requirements can be found on the website of the Kentucky Coalition of Nurse Practitioners and Nurse Midwives (www.kcn​pnm.org)
• KBN Notification of CAPA-CS
• Rescission for Collaborative Agreement for APRN Prescriptive Authority for Controlled Substances (CAPA-CS) Form
• Change of Practice Address for APRN with a CAPA-CS 

COMPLIANCE 

• Academic Performance Evaluation Form​.pdf
• Academic Verification Form.pdf
• Case Manager Monitoring Schedule.pdf
  
• Components of Mental Health and/or Chemical Dependency Evaluations 
• Counselor Evaluation Form.pdf
  
• Counselor/Therapist​ Verification Form.pdf
• Counselor Verification Form.pdf
• Employer Verification Form.pdf
  
• List of Evaluators by City 
• Meeting Documentation Form 
• Monthly Self Report 
• Prescription Medication Report.pdf
• Probation-Parole rpt.pdf
• Probation/Parole/Drug Court Verification Form.pdf
• ​Relapse Prevention Plan.pdf
• Treating Practitioner Verification Form.pdf
• Waiver of confidentiality.pdf
• Work Performance Evaluation Form.pdf​

DATA ROSTER DOWNLOAD 

• RN/LPN/APRN Data Roster Download
  • Layout for RN/LPN Database Roster
  • Layout for APRN Database Roster
• KNAR Data Roster Request Form
  • Layout for KNAR Database Roster
• SANE Data Roster Request Form
  • Layout for SANE Database Roster
• Instructions for Importing Text Files Into Microsoft Excel