IPASS PROCESSING

“Your International Exam Application Solution”

Kindly read the instructions carefully. Please complete the section below with details about
you. Information must be well filled in. Any missing information will be considered an
incomplete application and may cause a delay to your application.

1. Name as it appears on your UPDATED passport:

*First name :
*Middle name :
*Last name :
2. Name as it appears on your degree or other credentials (If different from personal information
section) :
Name as it appears on your Nursing Diploma: Name as it appears on your Nursing License
(Local/Foreign):
*First name : *First name :
*Middle name : *Middle name :
*Last name : *Last name :
3. If you are married, indicate your single name : 4. Facebook User Name:
*First name :
*Middle name :
*Last name :
5. Birthdate:
6. Gender:
7. Ethnicity:
8. Do you have a Social Security Number (USA) :
* Social Security number (USA) :
9. Your complete mailing address (Note : Do not put your Middle East address unless you are a
citizen. Instead you put your Philippine/US address):
*Complete mailing address : (House/Unit No., Floor & Bldg./ Street, Lot/ Blk, Brgy/Village)

*City/Municipality:
*Province/State:
*Zip Code:
*Country:
10. Mobile number (If you already put your US address above you must put both Philippine and US
Mobile Number for your NETCE and application) :

* Philippine Mobile number :

*Overseas Mobile number :

11. Email Address :

12. If you have ever taken the SBPT, NCLEX, or a state-constructed examination for license as either
a Registered Professional Nurse or a License Practical Nurse.
*State or Territory : *Exam Name :
*Profession : *License Number (If Granted) :
*Date Examination :

Note : Do not include your kindergarten. If you attended multiple schools please specify. Just COPY
and PAST the item below and fill in the details. If your schools’ change its name please indicate the
old and new name of it. Any missing information will be considered an incomplete application and
may cause a delay of your application.

13. Name of Elementary School :

*City/Municipality : *Number of Years Attended :

*State /Province : *Month and Year Started :
*Country: *Month and Year Completed :
14. Name of High School :

*City/Municipality : *Number of Years Attended :

*State /Province : *Month and Year Started :
*Country: *Month and Year Completed :
15. Name of College :

*Complete schools’ address : (No., Street District/Town)

*City/Municipality : *Month and Year Started :

*State/Province : *Month and Year Completed :
*Country: *Course :
*Number of Years Attended :
16. Current/Previous Professional Licenses and Certificates (This is for Endorsement only)
*Profession : *License Number (If Granted) :
*State or Territory : *Limitations/Privileges on License/Certificates :
*Date License/Certificate Issued :
17. Citizenship/Immigration Status:

*Type of Visa :

*Registration number or control number issued by the United States Citizenship and Immigration
Services (USCIS) :

Note: Once paid your application can no longer be editable.

Please provide the following for your document to upload with your application. Make sure that the
documents are CLEAR AND NOT CUT.

1. Scanned copy of NURSING DIPLOMA

2. Scanned copy of your UPDATED PASSPORT
3. Scanned copy of your TOR
4. Scanned copy of BIRTH CERTIFICATE (Applicable for married only)
5. Scanned copy of MARRIAGE CERTIFICATE/CONTRACT (If applicable for Female only)
6. Scanned copy of your updated PRC ID (Back & Front with signature)
7. Scanned copy of your BOARD RATING (If available)

Once the application is completed, you will receive an email with your application ID (please keep
your APPLICATION ID) and confirming that the application has been submitted to New York Board of
Nursing.

UPDATE APRIL 2019