Licensure Applications and Forms:

REGISTERED NURSE (RN) AND LICENSED PRACTICAL NURSE (LPN) APPLICATIONS

NOTE: Applications and forms that are pdf fillable will display with boxes to enter text and dropdown boxes to make selections. You may enter data directly into these form. Some forms and applications require notarizing, signatures, or other requested information that necessitates that they be printed in order to complete. All completed forms and applications should be returned to: Mississippi Board of Nursing, 1080 River Oaks Drive, Suite A100, Flowood, MS 39232.

RENEWALS

• RN RENEWAL:  This application should be used by registered nurses who wish to renew their license during a current renewal period (October 1 through December 31 – even numbered years)

• LPN RENEWAL:  This application should be used by licensed practical nurses who wish to renew their license during a current renewal period (October 1 through December 31 – odd numbered years). Expanded Role LPNs (IV Therapy and/or Hemodialysis) must complete a LPN Expanded Role Renewal Application and submit it with the LPN Renewal Application. If you choose not to renew your exapnaded role please complete and return the LPN Expanded Role Renewal Application and select that you do no wish to renew. (pdf fillable form)

• LPN EXPANDED ROLE RENEWAL: This application should be used by licensed practical nurses who wish to renew their expanded role certification in IV Therapy or Hemodialysis and are required to complete a minimum of 10 contact hours directly related to the expanded role during a current renewal period (October 1 through December 31 - odd numbered years). (pdf fillable form).

• INACTIVE LICENSE: Submit this form to change RN or LPN licensure status from active to inactive. A nurse holding an inactive license can not practice as a licensed nurse. (pdf fillable form)

EXAMINATION

• LICENSURE BY EXAMINATION:  Application for licensure by NCLEX-RN or NCLEX-PN.  This application should be used by candidates seeking licensure by examination, including those who need to repeat the NCLEX examination. Click here for the examination registration process. (pdf fillable form)

   

  • NCLEX SPECIAL ACCOMODATIONS: This application should ONLY be submitted by applicants requesting special accomodations for the NCLEX. (pdf fillable form)

ENDORSEMENT

• LICENSURE BY ENDORSEMENT:  This application should be used to obtain licensure in Mississippi if a currently licensed registered nurse or licensed practical from another state has never held a Mississippi license. (pdf fillable form)

   

  • CAMP NURSE: The board, Pursuant to the Miss. Code Ann. Section 75-74-8, may issue a ninety (90) day temporary permit to practice nursing at a youth camp to qualified applicants upon receipt of a completed application and fee. The applicant must hold an active and current license in another jurisdiction. (pdf fillable form)

REINSTATEMENT

• RN REINSTATEMENT:  For registered nurses who once held a Mississippi license and wish to make it active again. This application should be used by registered nurses that have allowed their license to lapse or are changing licensure status from inactive to active. (pdf fillable form)

• LPN REINSTATEMENT:  For licensed practical nurses that once held a Mississippi license and wish to make it active again. This application should be used by licensed practical nurses that have allowed their license to lapse or are changing licensure status from inactive to active. (pdf fillable form)

• REORIENTATION PERMIT APPLICATION: This application is for registered nurses or licensed practical nurses that are enrolled in a reorientation/refresher course requiring a clinical component. Please contact the Board office at 601-664-9303 to obtain this application.
   

LPN EXPANDED ROLE (IV THERAPY AND HEMODIALYSIS)

• RN INSTRUCTOR PACKET: LPN EXPANDED ROLE IV THERAPY AND/OR HEMODIALYSIS:  (pdf fillable form)

For qualified registered nurse instructors, to provide an IV and/or hemodialysis course for currently licensed practical nurses with at least one (1) year of clinical experience within the past three (3) years. It contains the application and forms that should be completed by the licensed practical nurse and registered nurse instructor. The packet should not be completed for or by LPN graduates from an approved nursing program with an integrated IV curriculum. This application is not intended for independent registered nurses pursuing entrepreneurship opportunities.

• LPN REINSTATEMENT EXPANDED ROLE APPLICATION:  For licensed practical nurses who once held an expanded role (IV therapy and/or hemodialysis) certification and would like to make it active again. Use this application if you have allowed your expanded role certification to lapse.

CERTIFIED CLINICAL HEMODIALYSIS TECHNICIAN (CCHT) APPLICATIONS 

• CCHT APPLICATION:  This application should be used for CCHT candidates seeking initial, repeat or endorsement certification as a CCHT in Mississipi. Select repeat only if you have previously submitted an initial CCHT application to Mississippi and are resubmitting after a failed testing attempt. Select endorsement only if you are currently certified and have worked as a hemodialysis technician in another state, and have never held a Mississippi CCHT certification.

• CHT RENEWAL:  This application should be used for CHTs to renew their Mississippi certification during a current renewal period (May 1 through July 31 – odd numbered years).

• CCHT REINSTATEMENT: This application should be used for CHTs who once held a Mississippi certification and wish to become certified again. Use this application if you have allowed your certification to lapse.

ADVANCED PRACTICE REGISTERED NURSE (APRN) APPLICATIONS 

ADVANCED PRACTICE INITIAL CERTIFICATION APPLICATION 

• APRN INITIAL CERTIFICATION APPLICATION:  This application should be used to obtain certification in Mississippi if a currently licensed RN/APRN has never held a Mississippi certification.

  ADVANCED PRACTICE REINSTATEMENT APPLICATIONS

• APRN REINSTATEMENT:  For nurse practitioners who once held a Mississippi certification and wish to make it active again. This application should be used by APRNs who have allowed their certification to lapse.

FORMS

• PRIMARY STATE OF RESIDENCY DECLARATION: Use this form to declare primary state of residency. If you are requesting a primary state of residency change to Mississippi and hold a single state license issued by Mississippi you should complete this form. (pdf fillable form)

• CHANGE OF ADDRESS FORM: Use this form to inform the Board of your address changes. This form should only be used by licensed Mississippi nurses. Do not use this form to change your primary state of residency; see primary state of residency declaration form above. (pdf fillable form)

• NAME CHANGE: Use this form to inform the Board of your name change. This form must accompany legal documentation (i.e., marriage certificate, divorce decree).  (pdf fillable form)

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