For Office Use Only:

Texas Board of Nursing

Amount

333 Guadalupe, Ste. 3-460, Austin, TX 78701-3944

Phone: 512-305-7400 -- Web Site: www.bon.texas.gov

RN

Date Recd

Timely License Renewal Form

This form may be used during the 60 days prior to the license
expiration.
Please refer to the enclosed General Instructions, checklist and
statistical code sheet to assist in completing this form.
Answer all questions, sign, date, and return both pages.

Processing time is within ten (10) business days once all requirements are
met.
The Rules pertaining to the maintenance of your license and your eligibility
to renew are located at 22 Texas Administrative Code (TAC) chapter 216
and 213.27, 213.28, 213.29, 213.33, 217.6 and 217.7.

Make your check or money order payable to the Texas Board of Nursing. Fees are non-refundable. The application and payment are valid for one year
from the date of receipt in the Boards office and all licensure requirements must be met within that timeframe.

[ ] TIMELY RN RENEWAL ONLY (prior to expiration date)

Fee: $60.00

Name(Last):

[ ] RN RETIRED LICENSE No Fee Required

Must be requested prior to license expiring
[ ] RN INACTIVE STATUS No Fee Required.
Must be requested prior to license expiring

(First):

(M):

Legal documentation is required for a name change (see 22TAC 217.7)

RN License Number:

Social Security Number:

Date of Birth:

/
Mo

(Address)

(City)

(State/Country)

**
(E-Mail Address)

/
Day

Yr

(Zip/Postal Code)

)
Business Fax Number

*For statistical information below, please use the statistical code sheet provided
*Employment Status:

*Primary Practice Setting:

*Primary Specialty:

*Highest Degree:

*Primary Practice Position:

*Primary Employment Zip:

In accordance with the Texas Occupations Code, section 304.001, art. 4 and 22 TAC 220.2, check one of the following:

I declare Texas as my primary state of residence and I have provided a Texas address. I am eligible for a Compact
Texas License (I understand that once my Texas license is renewed, my other compact state license(s) will be inactivated, if
applicable).
I declare Texas as my primary state of residence but I have not provided a Texas address. I am eligible for a Single
State Texas License only. (NOTE: If the address you provide is in a Compact State, the BON may seek clarification prior to renewing
the license)
I am declaring a Non-Compact State as my primary state of residency. My permanent residence is not Texas, and it is
a state not participating in the Nurse Licensure Compact (*). I am eligible for a Single State Texas License only. I declare that the
State of ________________________________ is my primary state of residence and that such constitutes my permanent and
principal home for legal purposes.
I am declaring another Compact State as my primary state of residency. My permanent residence is not Texas, and it is a
state participating in the Nurse Licensure Compact (*). Please put my Texas license on Inactive Status. I declare that the State of
________________________________ is my primary state of residence and that such constitutes my permanent and principal
home for legal purposes.
I am employed exclusively in the US military (Active Duty) or with the U.S. Federal Government and I am
requesting a Texas single-state license regardless of my primary state of residence. I declare that the State of
________________________________ is my primary state of residence and that such constitutes my permanent and principal
home for legal purposes.
(*) Refer to https://www.ncsbn.org/nlc.htm for a list of participating compact states and more detailed information about
the Nurse Licensure Compact.

[ ] No

[ ] Yes

Have you practiced nursing by using your nursing knowledge, skills and abilities within the past four (4) years?

In which states are you currently practicing nursing electronically

, or physically

, telephonically
. List all states that apply.

** Please note that your business fax number is being collected for use by an emergency relief program, as authorized by the Texas Occupations
Code 301.206 and is confidential and not subject to disclosure.

Licensees Name:

License Number:

Page 2 of 2

Eligibility Questions - Answering the questions below and signing the form is mandatory.
1) [ ] No [ ] Yes *Have you, within the past 24 months or since your last renewal, for any criminal offense, including those

pending appeal:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

been arrested and have any pending criminal charges?

been convicted of a misdemeanor?
been convicted of a felony?
pled nolo contendere, no contest, or guilty?
received deferred adjudication?
been placed on community supervision or court-ordered probation, whether or not adjudicated
guilty?
been sentenced to serve jail, prison time, or court-ordered confinement?
been granted pre-trial diversion?
been cited or charged with any violation of the law?
been subject of a court-martial; Article 15 violation; or received any form of military judgment/
punishment/action?

(You may only exclude Class C misdemeanor traffic violations or offenses previously disclosed to the Texas Board of Nursing on an initial
licensure or renewal application.)
NOTE: Expunged and Sealed Offenses: While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is
your responsibility to ensure the offense, arrest, ticket or citation has, in fact, been expunged or sealed. It is recommended that you
submit a copy of the Court Order expunging or sealing the record in question to our office with your application. Failure to reveal an
offense, arrest, ticket, or citation that is not in fact expunged or sealed may subject your license to a disciplinary order and fine. Nondisclosure of relevant offenses raises questions related to truthfulness and character. (See 22 TAC 213.27)
NOTE: Orders of Non-Disclosure: Pursuant to Tex. Govt Code 552.142(b), if you have criminal matters that are the subject of an
order of non-disclosure you are not required to reveal those criminal matters on this form. However, a criminal matter that is the subject
of an order of non-disclosure may become a character and fitness issue. Pursuant to the Govt Code chapter 411, the Texas Board of
Nursing is entitled to access criminal history record information that is the subject of an order of non-disclosure. If the Board discovers
a criminal matter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the Board may require
you to provide information about any conduct that raises issues of character and fitness.
2) [ ] No

[ ] Yes

*Are you currently the target or subject of a grand jury or governmental agency investigation?

3) [ ] No

] Yes

Has any licensing authority ever refused to issue you a license or ever revoked, annulled, cancelled,
accepted surrender of, suspended, placed on probation, refused to renew a license, certificate, or multistate privilege held by you now or previously, or ever fined, censured, reprimanded, or otherwise disciplined
you? (You may exclude disciplinary actions issued by the Texas Board of Nursing and disciplinary actions
previously disclosed to the Texas Board of Nursing on an initial licensure or renewal application.)

4) [ ] No

] Yes

*In the past 5 years, have you been diagnosed with or treated or hospitalized for schizophrenia or other
psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial personality disorder, or
borderline personality disorder which impaired or does impair your behavior, judgment, or ability to
function in school or work? (You may answer No if you have completed and/or are in compliance with
TPAPN for mental illness OR youve previously disclosed to the Texas Board of Nursing and have
remained compliant with your treatment regime and have had no further hospitalization since disclosure.)

5) [ ] No

[ ] Yes

*In the past 5 years, have you been addicted to or treated for the use of alcohol or any other drug? (You
may answer no if you have completed and/or are in compliance with TPAPN)

I attest that I understand and meet all the requirements to practice for the type of renewal requested. I understand that no one else
may submit this form on my behalf and that I am accountable and responsible for the accuracy of any answer or statement on this
form. Further, I understand that it is a violation of 22 TAC 217.12(6)(I) and the Penal Code, sec. 37.10, to submit a false statement
to a governmental agency.
Sign:

Date:
(SIGNATURE REQUIRED)

*Pursuant to the Texas Occupations Code 301.207, information, including diagnosis and treatment, regarding an individuals physical or mental
condition, intemperate use of drugs or alcohol, or chemical dependency and information regarding an individuals criminal history is confidential
to the same extent that information collected as part of an investigation is confidential under the Texas Occupations Code 301.466.

NOTE: IF YOU ANSWERED YES TO #1-5 PLEASE REFER TO INSTRUCTIONS

Revised 10/2016

STATISTICAL CODES
(Do not return this sheet)
HIGHEST DEGREE IN NURSING
1=
2=
3=
5=
7=
9=

DIPLOMA
ASSOCIATE DEGREE
BACCALAUREATE IN NURSING
MASTERS IN NURSING
DOCTORATE IN NURSING
VOCATIONAL NURSE/PRACTICAL NURSE PROGRAM

EMPLOYMENT STATUS
1=
2=
3=
4=
5=

EMPLOYED IN NURSING FULL TIME

EMPLOYED IN NURSING PART TIME
EMPLOYED IN OTHER FIELD FULL TIME
EMPLOYED IN OTHER FIELD PART TIME
UNEMPLOYED, RETIRED OR INACTIVE

PRIMARY PRACTICE POSITION:

1 = ADMINISTRATOR OR ASSISTANT
2 = CONSULTANT
3 = SUPERVISOR OR ASSISTANT
4 = FACULTY/EDUCATOR
5 = HEAD NURSE OR ASSISTANT
6 = STAFF NURSE/GENERAL DUTY
*7 = NURSE PRACTITIONER
*8 = CLINICAL NURSE SPECIALIST
*9 = NURSE ANESTHETIST
*10 = NURSE MIDWIFE
11 = INSERVICE/STAFF DEVELOPMENT
12 = SCHOOL NURSE
13 = OFFICE NURSE
14 = RESEARCHER
15 = OTHER:
(*) TEXAS BOARD OF NURSING APPROVAL REQUIRED

PRIMARY PRACTICE SETTING:

1=
2=
3=
4=
5=
6=
7=
8=
9=
10 =
11 =
12 =
13 =
14 =
15 =

INPATIENT HOSPITAL CARE

OUTPATIENT HOSPITAL CARE
SCHOOL OF NURSING
COMMUNITY/PUBLIC HEALTH
SCHOOL/COLLEGE HEALTH
SELF-EMPLOYED/PRIVATE PRACTICE
PHYSICIAN OR DENTIST/PRIVATE PRACTICE
RURAL HEALTH CLINIC
FREESTANDING CLINIC
HOME HEALTH AGENCY
MILITARY INSTALLATION
TEMPORARY AGENCY/NURSING POOL
NURSING HOME/EXTENDED CARE FACILITY
BUSINESS/INDUSTRY
OTHER:

PRIMARY SPECIALTY:
1=
2=
3=
4=
5=
6=
7=
8=
9=
10 =
11 =
12 =
13 =
14 =
15 =
16 =
17 =

COMMUNITY/PUBLIC HEALTH
GENERAL PRACTICE
GERIATRICS
OBSTETRICS/GYNECOLOGY
MEDICAL/SURGICAL
PEDIATRICS
PSYCHIATRIC/MENTAL HEALTH/SUBSTANCE ABUSE
ANESTHESIA
EMERGENCY CARE
HOME HEALTH
INTENSIVE/CRITICAL CARE
NEONATOLOGY
ONCOLOGY
OPERATING/RECOVERY CARE
REHABILITATION
OCCUPATIONAL/ENVIRONMENTAL HEALTH
OTHER:

GENERAL INSTRUCTIONS
(Keep for your own records)
In order to maintain your license, you must meet the requirements of 22 TAC Chapter 216 and 213.27, 213.28, 213.29,
213.33, 217.6 and 217.7, as applicable and pay the appropriate fee. "A registered nurse who practices professional nursing
or a vocational nurse who practices vocational nursing after the expiration of the nurses license is an illegal practitioner
whose license may be revoked or suspended. Texas Occupations Code 301.301(f).

ACTIVE APPLICATIONS
An application and payment are considered to be active for up to one year from the date of receipt in the Boards office per
our Records Retention Policy. All licensure requirements must be met within that years timeframe or the application and
payment will be considered null and void. Should this occur, a new application and payment would need to be submitted;
and the nurse will need to meet all current requirements in effect at that time.

GRACE PERIOD
Nurses who submit the timely renewal application and correct minimum payment, postmarked no later than the last day of
the month the license is due to expire are exempt from TOC 301.301(f) and may continue to practice for a period of up to
one month from the license expiration date while the renewal is in process. The Renewal Department will communicate
with the nurse regarding any outstanding licensure issues (i.e. need for a TGSLC release letter, compliance with continuing
competency audit etc). If all renewal requirements are not met within the subsequent month, the license will be placed on
delinquent status.
During the grace period, the website will reflect that the license is current though the expiration date has passed. The
BON website will be updated to reflect the future expiration date once the renewal process is completed. A nurse who
does not submit the timely renewal application and correct payment, postmarked on/before the license expiration date,
must follow the delinquent renewal process and no grace period will apply.

PRIMARY STATE OF RESIDENCE

Declaring a compact state, other than Texas, will cause your renewal to be rejected since you can practice in Texas on
your declared compact state license. In addition, the BON reserves the right to seek clarification when needed. Per Rule
220.2(b), primary state of residence is determined by the following documents and you may be requested to submit one or
more to satisfy residency requirements:
(1) a drivers license with a home address;
(2) voter registration card displaying a home address;
(3) federal income tax return declaring the primary state of residence;
(4) Military Form No. 2058 - state of legal residence certificate; or
(5) W2 from US Government or any bureau, division or agency thereof indicating the declared state of residence.

For more information regarding the compact, visit our website at www.bon.texas.gov or the National Council of State
Boards of Nursings website at https://www.ncsbn.org/nlc.htm.

CONTINUING COMPETENCY
If this is the first timely renewal of your Texas nursing license, Continuing Competency (CC) requirements are
waived. Otherwise, you are required to complete 20 contact hours of continuing competency that meet the Boards criteria
set out in 22 TAC Chapter 216 prior to applying for the renewal of your license.

NAME CHANGE
For a name change, you must submit a copy of legal documentation, (e.g., valid marriage license, divorce decree,
corrected drivers license), which states the name change.

COPIES OF LICENSES
Reminder: No More Paper Licenses Upon Renewal After September 1, 2008. The Board of Nursing discontinued
issuing wallet-sized paper licenses for nurses renewing their licenses after September 1, 2008. Nurses and nurse
employers should go to the Boards website at www.bon.texas.gov to verify a license online. The verification, once
printed, will resemble a license and will allow you to have the document laminated for the purpose of carrying.

CRIMINAL BACKGROUND CHECK

If you have not previously completed a criminal background check for the Texas Board of Nursing, or the BON does not
have a disposition with a state identification number on file for fingerprints previously submitted, you may be required to
complete the process at this time. You will be notified by our office if this is a requirement.

INACTIVE STATUS
If your nursing license is current and in good standing, you may be eligible to request inactive status. [See 22 TAC
217.9 for more information.] Check the appropriate box on the front of the renewal form, complete all applicable areas
and mail the form to the Boards address listed at the top of the renewal form. No fee is required. If you desire to reenter the practice of nursing in Texas, you will be required to pay a reactivation fee and meet all current requirements
in effect at the time you desire to re-enter the practice of nursing.

RETIRED STATUS
If your nursing license is in good standing with the Board you may apply for retired status. [See 22 TAC 217.9 for more
information.] Check the appropriate box on the front of the renewal form, complete all applicable areas and mail the
form to the Boards address listed at the top of the renewal form. A nurse whose license is in retired status may not
practice as a nurse. If you desire to reactivate your Texas nursing license to a current status, you will be required to
pay a reactivation fee and meet all current requirements in effect at that time.
VOLUNTEER RETIRED STATUS
If your nursing license is in good standing with the Board according to Rule 217.9 (b), you may apply for volunteer retired
status. You will need to download the Volunteer Retired Nurse Authorization Form
(http://www.bon.texas.gov/licensure_renewal.asp). Complete the form and mail it to the Boards address listed at the top
of form. A nurse whose license is in volunteer retired status may practice voluntarily (such practice must be without
compensation or expectation of compensation as a direct service volunteer of a charitable organization), and must
meet the requirements of 22 TAC 217.9, 217.11, 217.12 and Chapter 216. If you desire to reactivate your Texas
nursing license to a current status, you will be required to pay a reactivation fee and meet all current requirements in
effect at that time.
LATE RENEWALS
According to the Texas Occupations Code, 301.301(c), any application for renewal postmarked after the expiration
date shall be charged a late fee. If your nursing license has expired, then you may not use this form. You will need to
download the applicable delinquent renewal form (http://www.bon.texas.gov/licensure_renewal.asp) There is no
Grace Period for those nurses who postmark the renewal application and payment AFTER the license has
expired.

Renewal Form Checklist

- (Do not return this sheet)

Checked type of renewal?

Have you answered all the questions on the renewal form?
Have you signed and dated the renewal form?
Have you enclosed the appropriate fee? (if applicable)
Have you completed 20 hrs of Continuing Competency that meet the criteria in 22 TAC Chapter
216? (if applicable)
Did you read the instructions regarding Primary State of Residence? Note: Declaring a compact state,
other than Texas, will cause your renewal to be rejected.

GENERAL INSTRUCTIONS - Continued

If you answered yes to questions 1-5 of the Eligibility Questions on page 2, you must provide the Board with the following
information:
*QUESTION #1 The Board has determined that criminal behavior is highly relevant to an individuals fitness to practice nursing.
Therefore, all criminal convictions or deferred orders, prosecution, or adjudication, a determination by a court that is withheld or delayed
for a specific time period, must be reported to the Board. This question includes offenses under the law of another state, federal law, or
the Uniform Code of Military Justice that contains elements of criminal conduct. SUBMIT a personal letter of explanation describing each
incident, the behavior that led up to the criminal order and your conduct since the order, and any rehabilitative efforts that have been
performed since the order. In addition, SUBMIT the following documentation for all felonies, all misdemeanors, and all military actions:
Certified copies of:
1.
charges (indictment, information, or complaint);
2.
disposition of charges (Judgment, Order of Probation, Sentence, and/or Deferred orders); and
3.
evidence that the conditions of the court have been met.
(To obtain this documentation, contact the county clerk in the jurisdiction where the order was issued for misdemeanors; district court
clerk for felonies. If the record does not exist, you must obtain a statement from that court that the document has been destroyed or
could not be located.)
You may answer NO to the question of prior convictions only if you: (a) received a pardon; or (b) were adjudicated as a minor without
a finding of delinquent conduct. If you were ever required to register as a sex offender, you must answer YES.
If you have questions regarding the outcome of any criminal matter, consult your attorney.
*QUESTION #2 The Nursing Practice Act provides that a persons conduct in violation of the Nursing Practice Act or rules of the Board
may be considered as a factor in its deliberations regarding fitness to practice nursing. Therefore, if a licensee or applicant is the subject
of a grand jury or governmental agency investigation, the information regarding conduct or behavior giving rise to the investigation may
be relevant in determining a violation of the Nursing Practice Act or lead to the admissibility of relevant evidence of such violation. If you
are the subject of a grand jury or governmental agency investigation, please SUBMIT the name and address of the investigating entity
and an explanation as to the basis of the investigation.

QUESTION #3 The Board has determined that if any licensing authority has taken disciplinary action against a person for any reason,
then those actions are highly relevant to an individuals current ability to practice nursing in the state of Texas. If any licensing authority
has refused to issue a license, revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew
a license, certificate, or multi state privilege held by you or previously fined, censured, reprimanded or otherwise disciplined you, SUBMIT
the names and address of the licensing authority who has taken action and a letter explaining the background of the action. Additionally,
SUBMIT certified copies of:
1. formal charges or allegations supporting the licensure action;
2. final disposition of the licensing authority regarding those formal charges or allegations; and
3. evidence that the conditions of the licensing authoritys order or requirements have been met.

*QUESTION #4 The practice of nursing requires current fitness. The Board has identified certain disorders which, if occurring within the
last 5 years, may indicate a lack of fitness. The disorders are: schizophrenia and other psychotic disorders, bipolar disorder, paranoid
personality disorder, anti-social personality disorder, or borderline personality disorder. If you have been diagnosed, treated, or
hospitalized for any of the above illnesses within the last 5 years, which impaired or does impair your behavior, judgment, or ability to
function in school or work, submit the following information that will allow the Board to conduct an individualized assessment of your
ability to practice safely, competently, and without impairment to your professional judgment, skill, or knowledge.
1. A report, on letterhead, from your physician, psychiatrist, psychologist or counselor, sent directly to this office, that includes: your
diagnosis; treatments rendered; including current medications; prognosis; cognitive, affective, and emotional stability and continuing
after-care recommendations, including reasonable accommodations needed to safely practice nursing, if any; and,
2. Verification of compliance with aftercare recommendations.
Please be advised that a physical/psychological evaluation may be requested as part of your individualized assessment. The
evaluation process is described in more detail at www.bon.texas.gov/disciplinaryaction/eval-guidelines.html.
The evaluation process could potentially delay consideration of your renewal. Therefore, the Board is providing advance notice of this
possibility so that applicants may contact the Board to schedule an evaluation at the beginning of the renewal process. By doing so,
the renewal should not be unduly delayed. An applicant is not required to contact the Board in advance of Board consideration of the
renewal. The applicant may choose to wait for a specific decision by the Board that a specific evaluation is necessary. This
information is being provided to put applicants on notice with respect to this potential requirement and afford the applicant the
opportunity to expedite the process if he/she so desires.

*QUESTION #5 The practice of nursing requires current sobriety and fitness. If you have been addicted to or treated for the use of
alcohol or any other drug within the last five years, SUBMIT:
1. verification of treatment for substance abuse sent directly to the Board from the treatment center;
2. verification of compliance with aftercare recommendations;
3. evidence of continuing sobriety/abstinence; for example, current support group attendance and random drug testing results;
and
4. a personal letter of explanation with sobriety date and plan for relapse prevention.
*Pursuant to the Texas Occupations Code 301.207, information, including diagnosis and treatment, regarding an individuals physical
or mental condition, intemperate use of drugs or alcohol, or chemical dependency and information regarding an individuals criminal
history is confidential to the same extent that information collected as part of an investigation is confidential under the Texas
Occupations Code 301.466.