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1 K e n t u c k y Bo ar d o f N urs i n g 31 2 Whit t ingt o n P k y St e 300 Louisville KY 40 2 22 - 5172 w w w . kb n . k y . g o v 502 42 9 - 3300 800 - 305 - 2 0 42 CERTIFIED PROFESSIONAL MIDWI F E APPLICATION FOR LICENSURE A PPL I C A T IO N FEE I S N O N - R E F U N D A BLE A ND S U B J E C T TO CH A N G E Office U s e Only Sectio n 1 : Biographical Data ______________________________________________________________________________________________________________ Las t N a m e (print clearly) ______________________________________________________________________________________________________________ Firs t N a m e (pr i n t cl ear l y ) ___________________________________________________________________ Midd l e N a m e ( p rint clear l y ) __________ - __________ - _____________ __________________________________________ _______└──┴ ─ ─┴─ ─┘ └──┴ ─ ─ ┘ └──┴ ─ ─┴─ ─ ┴──┘ __________ / _________ / ___________ Social Se c u ri t y # (print clear l y ) Dat e of Bi r t h ________________________________________________________________________________________________________________________ A ddre s s ( p rint clear l y ) ________________________________________ ___________ _________________________ Ci t y ( p r i n t cl ear l y ) Stat e Zi p C od e (prin t c l ear l y ) _____________________________________________________________ Co u n t y o f R esi de nc e ( p rint clearly) ______________ - ______________ - ______________ - _______________ - ______________ Primary Phone Num b er ( p rint clear l y ) Secondary P h o n e N um b e r (pr i n t cl e a r l y ) Email A ddress (print clear l y ) _________________________________________________________________________ E thn ic G ro u p:  Ma l e  F e m a le  Unspecified  A f ric a n A m e ri c a n  N ativ e A m e ri c an  A sia n  Pac i fi c Is l a nder Are you a U.S . Citizen ?  Y e s  No  Hispani c o r Latino  W hite  Multiracial  O th e r Sectio n 2 : Method of Application  Initial - Fee $1000  R einstatement - Fee $1000 2 Sectio n 3 : CPM Educational P r og r am In f o rmation Pleas e an s w e r th e f o ll o w i n g q u esti o n s a b o ut t h e CPM progr a m y ou a t te n ded. _____________________________________________________________________________________________________________ Name (print clearly) ______________________________________________________ ______________ ___________ / ________________ Ci t y ( p r i n t cl ear l y ) Stat e Mon th & Yea r C omp l e t e d Is the program you attended MEAC approved?  Y es  No If yes, an official transcript must be sent from the program you attended. If no, in lieu of transcript you must submit the Midwifery Bridge Certificate . Please include :  NARM Certification,  Proof of completion of the D omestic V iolence course pursuant to KRS 194A.540 ,  Proof of completion of the Pediatric Abusive Head Trauma course pursuant to KRS 620.020(8)  NRP Certification,  AHA BLS Certification,  Proof of

licensure in another state (if applicable) Sectio n 4 : Disciplinary If y ou an s wer “ y e s” to a n y of these questions, y ou SH A LL provide t h e follo w ing doc u ments as indica t ed bel o w : 1. A detailed letter of e x planation for each action t a ken. 2. A certified copy of the B o ard’s or other licensing agen c y ’s action. 3. If y ou have m ore than t w o disciplinary events, please li s t the ev e nt and state and year received on a separate piece of paper. Check the a pp r opriate boxes a nd fill out info r m at i on for ea c h “ y es” an s w er: Do y ou have a c urre nt investigatio n , disciplina r y action or a c o m plaint pending on y our CPM license or other p r ofessional license/certificati o n? Are you c u rrent l y a p a rticipant i n a sta t e board / designee m onito r ing p r ogram including alte r native to discipline, dive r sion, or a peer assistance p r og r a m ? Has any licensing or re gulato r y a u thority in any U.S. state or ju r isdiction EV ER denied, l i m ited, suspended, p r obated, re voked, o r ot herw ise disciplined a p r ofessi o nal or occupational lice n se or c e rtificate that you held?  Y es  No State: Y e a r :  Y es  No State: Y e a r :  Y es  No State: Y e a r : Y es, t y pe of license(s)/certification(s): __ State: Y e a r : State: Y e a r : State: Y e a r : Sectio n 5 : Crimina l Histor y * Per KRS 314.011 (21) Convictio n s include conditional disc ha rge, pre t rial diversion, pleading no c ontest, nolo contend r e or entered an Alfo r d plea. You S H A LL REPORT ALL fe l o n y co n v i c ti o n s a nd pr o v i de cert i fi e d c o urt reco r d s and a detai l ed l e tter of e x plan a tion. If y ou have m ore than t w o convi c tions, please list t he conviction and state and year received on a separate piece of p aper. Mail all documentation to t h e KBN address. Have y ou ev e r b een convicted of a felo n y ?  Y e s  No State _______________________ __________ _______ Year __________________________ _______________ Conviction _________________________ ___________ State ________________________________________ Year ________________________ _________________ Conviction ____________________________________ If y es, has this conviction (s) been previously re p orted to KBN?  Y es  No 3 Sectio n 5 : Crimina l Histor y (cont) * Per KRS 314.011 (21) Convictio n s include conditional disc ha rge, pre t rial diversion, pleading no c ontest, nolo contend r e or entered an Alfo r d plea. You S H A LL REPORT ALL mi s d e mea n or c o n v ict i ons If y ou have m ore than t w o convi c tions, please list t he conviction and state and year received on a separate piece of p aper. Mail all documentation to t h e KBN address. Have y ou ev e r b een convicted of a misdemeanor i ncluding DUI?  Y es  No If the conviction* (including DUI) is less than five years old, y ou sh a ll provide certifi e d court records and a detailed letter of e x planation. If the conviction* (including DUI) is more than five years old, no ad d itional documentation is required to be submitted unless requested b y KBN. State ________________________________________ Year _________________________

________________ Conviction ____________________________________ State _____________________________________ ___ Year _________________________________________ Conviction ____________________________________ If y es, has this conviction(s) been previously re p orted to KBN?  Y es  No Sectio n 6 : Reinstatement of a CPM License _________________________________ _____________ / __________________ CPM License # (print clear l y ) Date Your CPM License L a psed (MM/YYYY) Y ou must sh o w p r oof of:  C urrent certification with NARM,  NRP Certification, and  AHA BLS Certification Sectio n 7 : Responsibility and Accountability of Licensed CPM KRS 314.02 1 (2): All individuals licensed under pr o visions of this c h apter shall be re s ponsible and accountable for mak i ng decisions that are based u p on the individual’s e ducational prep a ration and e x p e rience and shall practice w ith rea s onable skill and s afe t y . http://kbn. k y .gov / legalopinions/P a ges/la w s.asp x . Sectio n 8: Attestation Statement I certi f y that I am the person referred to in the fore g oing application that all statements c o ntained herein and on a l l at t ac h m e nt s a r e t r u e a n d c or re c t i n ev er y r es p ect ; a n d t h a t I ha v e r ea d a n d u n d er s t a n d thi s a pplic a ti o n a n d al l r e qu i r e m en t s s t at e d t h e r e in . I f u r t h e r u n d e rst a nd tha t al l inf o rmati on o n thi s a p plicatio n i s subjec t t o an audi t f or v e rificatio n a n d tha t th e falsificatio n of a ny in f or m atio n co n t aine d h e rei n wil l b e cause for disci p linary action. Applicant’s Signature / / Date 1/2020 3 1 CERTIFIED PROFESSIONAL MIDWI F E APPLICATION FOR LICENSURE A PPL I C A T IO N FEE I S N O N - R E F U N D A BLE A ND S U B J E C T TO CH A N G E Office U s e Only Sectio n 1 : Biographical Data ______________________________________________________________________________________________________________ Las t N a m e (print clearly) ______________________________________________________________________________________________________________ Firs t N a m e (pr i n t cl ear l y ) ___________________________________________________________________ Midd l e N a m e ( p rint clear l y ) __________ - __________ - _____________ __________________________________________ _______└──┴ ─┴─ └──┴ ─┴─ ┴──┘ __________ / _________ / ___________ Social Se c u ri t y # (print clear l y ) Dat e of Bi r t h ________________________________________________________________________________________________________________________ A ddre s s ( p rint clear l y ) ________________________________________ ___________ _________________________ Ci t y ( p r i n t cl ear l y ) Stat e Zi p C od e (prin t c l ear l y ) _____________________________________________________________ Co u n t y o f R esi de nc e ( p rint clearly) ______________ - ______________ - ______________ ______________ - _______________ - ______________ Primary Phone Num b er ( p rint clear l y ) Secondary P h o n e N um b e r (pr i n t cl e a r l y ) Email A ddress (print clear l y ) _________________________________________________________________________ E thn ic G ro u p: Ma l e F e m a le Unspecified A f ric a n A m e ri c a n N ativ e A m e ri c an A sia n Pac i fi c Is l a nder Are you a U.S . Citizen ? Y e s No Hispani c o r Latino W hite Multiracial O th e r Sectio n 2 : Method of Application Initial - Fee $1000 R einstatement - Fee $1000 Kentuck\BoardNursin