The New Mexico Board of Nursing form serves as a formal declaration regarding the status of an expired or lapsed nursing license or certification. This document requires individuals to affirm their understanding of the implications of their lapsed status and provide necessary details about their work history during that period. Timely submission of this form is crucial to avoid potential disciplinary actions against one's nursing credentials.
The New Mexico Board of Nursing form, specifically the Attestation of Expired/Lapsed License/Certificate, plays a crucial role for nursing professionals in the state. This form is designed for individuals whose licenses or certifications have expired or lapsed, requiring them to provide a sworn statement regarding the circumstances surrounding this situation. It begins with a declaration of the individual’s name and birth date, followed by an explanation of why the license was allowed to lapse. The form also includes important sections where the individual must confirm whether they have worked in the state during the period their license was expired. This requires the submission of supervisor details, including name, contact information, and the number of days worked. Furthermore, it emphasizes the importance of returning the completed form and any necessary supporting documents to the New Mexico Board of Nursing within a specified timeframe to avoid potential disciplinary actions. The form concludes with an affirmation of truthfulness, underscoring the seriousness of providing accurate information. By completing this form, nursing professionals take a significant step toward reinstating their licensure and continuing their vital work in healthcare.
NEW MEXICO BOARD OF NURSING
ATTESTATION OF EXPIRED/LAPSED LICENSE/CERTIFCIATE
On this _________ day of _______________, 20______, I ___________________________, born on
(Print Name)
________________, swear and affirm as follows:
1.That I allowed my New Mexico License/Certification to expire/lapse. The reason for allowing this to occur is as follows:
______________________________________________________________________________
Attach additional documents if necessary.
2.Please answer either question A or B below:
a.I attest that I did NOT work any hours/shifts in the State of New Mexico or another compact State, since the date in which my license expired/lapsed: ___________.
(Initial)
OR
b.I attest that I DID work on an expired/lapsed license. __________.
i.Supervisors Name: _____________________________
ii. Supervisors Telephone: (
) ___________________
iii.Supervisors email Address: _____________________________
iv.Number of days/shifts worked in the State of New Mexico since the date in which my license expired/lapsed: __________________________
v.I have attached a list or payroll records of all dates and hours worked at a job related to my license/certificate from this day going back to the date when my license/certificate expired. ___________. (This also needs to be signed by your
supervisor).(Initial)
3.I understand this attestation as well as any supporting documents need be returned to the NMBON no later than 5 business days following the date of submission of my renewal application. Failure to provide this attestation within the time period required could result in disciplinary action taken towards my New Mexico licensure/certificate ___________.
I swear or affirm that the above and foregoing representations are true and correct to the best of My information, knowledge, and belief.
____________________
__________________________
______________
Print Name
Signature
Date
Any misrepresentation on this attestation can lead to disciplinary action and will be forwarded to the Compliance Division for investigation.
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