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Fill in Your Mississippi Nurse Renewal Template

The Mississippi Nurse Renewal form is a crucial document that registered nurses must complete to renew their nursing licenses in Mississippi. Timely submission of this form is essential, as failure to renew by the expiration date can lead to penalties and an invalid license. Ensure you fill out the form accurately and submit it promptly by clicking the button below.

Make This Mississippi Nurse Renewal

Fill in Your Mississippi Nurse Renewal Template

Content Overview

For registered nurses in Mississippi, staying compliant with state regulations is crucial, and the Mississippi Nurse Renewal form serves as a key tool in this process. This form is essential for renewing your nursing license, which must be done before the expiration date to avoid penalties. The renewal fees vary based on your status—active, inactive, or advanced practice registered nurse (APRN)—with specific amounts outlined for each category. It’s important to note that failure to renew by the deadline will render your current license invalid, leading to additional reinstatement fees. If you’ve changed your name, there’s a separate procedure involving documentation and a small fee. Furthermore, the form requires you to specify your primary state of residence, which is particularly significant for those practicing under multi-state licensure agreements. If you or your spouse works in a federal or military facility, proof of Mississippi residency is necessary. Additionally, if you decide not to renew your license, a written notification to the Board is required. Remember, license wallet cards are no longer distributed, but you can easily check your licensure status online. Completing the form accurately and submitting it on time is vital for maintaining your professional standing in the nursing community.

Mississippi Nurse Renewal Preview

MISSISSIPPI BOARD OF NURSING

713 S. Pear Orchard Rd, Suite 300

Ridgeland, MS 39157

(601) 957-6300

2014

REGISTERED NURSE RENEWAL

INSTRUCTIONS

1.Make fee payable to: Mississippi Board of Nursing

2.Renewal Fees: Active $100.00; Inactive $25.00; Advanced Practice Registered Nurse (APRN) $100.00; (additional certification $50.00 each); Controlled Substance Prescriptive Authority (CSPA) $50.00. Include your phone number and social security number and/or nursing license number on your payment. Cash will not be accepted.

3.Your current license becomes INVALID and a PENALTY WILL BE ASSESSED if not renewed by the expiration date of DECEMBER 31, 2014.

4.After the expiration date of current license, the Reinstatement fees are: Active $100.00 (plus additional fee); Inactive $25.00; Advanced Practice Registered Nurse (APRN) $100.00 (additional certification $50.00 each) and Controlled Substance Prescriptive Authority (CSPA) $50.00.

5.Name change requires a fee of $25.00, copy of marriage license, divorce decree or other legal documents indicating name change should be submitted directly to this office.

6.Advanced Practice Certification is only for the State of Mississippi.

7.If you are an APRN, complete both a RN and APRN form in order to renew your APRN certification.

8.Primary state of residence/home – is the state that is the nurse’s “declared fixed permanent and principal home for legal purposes.”

9.Multi-state licensure means you may practice as a RN pursuant to your Mississippi RN license, not in an expanded role, in any Compact state unless you have had an action limiting your privilege to practice in the other Compact state. If you change primary state of residency to another compact state you will need to obtain licensure in your new state within thirty (30) days.

10.If you or your spouse is working in a federal/military facility and Mississippi is your primary state of residence, you should include proof of Mississippi residency.

11.If you do not wish to renew your RN license, please notify the Board office in writing.

NOTE: License wallet cards will no longer be distributed. You or your employer may check licensure status by accessing

the online licensure verification at www.msbn.ms.gov.

DO NOT RETURN THIS INSTRUCTION PAGE TO THE MISSISSIPPI BOARD OF NURSING.

Revised 09/2014

MISSISSIPPI BOARD OF NURSING

713 S. Pear Orchard Rd., Suite 300

Ridgeland, MS 39157

(601) 957-6300

2014 REGISTERED NURSE RENEWAL APPLICATION

NON-REFUNDABLE FEES

Active	$100.00
Inactive	$ 25.00

Any statement made on this application which is false and known to be false by the applicant at the time of making such statement shall be deemed fraudulent and will subject the applicant to disciplinary proceedings.

LICENSE # ______________________ SS # ___________________________ PHONE # ____________________________________

NAME________________________________________________________________________________________________________

First	Middle		Maiden	Last
ADDRESS__________________________________________________________ EMAIL ___________________________________
P.O. Box/Street	City	State	Zip	County

My primary state of residence is: _____________________________

PLEASE CIRCLE CORRECT INFORMATION

GENDER	HIGHEST DEGREE HELD		MAJOR CLINICAL AREA		MAJOR FIELD OF EMPLOYMENT
1. Male	5.	Diploma	1.	Gerontology	1.		Hospital
2. Female	6.	Associate Degree Non-Nursing	2.	Obstetric/Gynecologic	2.		Nursing Home
	7.	Associate Degree Nursing	3.	Medical/Surgical	3.		Private Duty
DATE OF BIRTH
	8.	Baccalaureate Non-Nursing	4.	Pediatric/Child Health	4.		Community/Public Health

_____-_____-_____	9.	Baccalaureate Nursing	5.	Psychiatric/Mental Health	5.		Home Health
	10. Masters Non-Nursing		6.	General Practice	6.		Office Nurse (Physician/Dentist/NP)

	11. Masters Nursing Education		7.	Community/Public Health	7.		Federal/Military
MARITAL STATUS	12. Masters Nursing Administration		8.	Critical Care	8.		Industry
1. Single	13. Masters Nursing Advanced		9.	Emergency Care	9.		Nursing Education Program
2. Married		Practice	10. Dialysis		10. School/Student Health Services
	14. Masters Nursing Other		11. Oncology		11.		Occupational Health
	15. Doctorate Nursing Science		12. Rehabilitation		12.		Self Employed (Except Private Duty)
	16. Doctorate Science Nursing		13. OR/RR/Anesthesia		13.		Hemodialysis
	17. DNP Clinical		14. Quality Assurance		14.		Other(Specify)______________
	18. DNP Non-Clinical		15. Education
	19. PhD Non-Nursing		16. Neonatology
	20. PhD Nursing		17. Home Health
	EMPLOYMENT STATUS		18. Other(Specify)___________

ETHNIC INFORMATION	1.	Nursing Full-time
	2.	Nursing Part-time
1. White (not of Hispanic			TYPE OF POSITION		ADVANCED PRACTICE
	3.	Other Field Full-time
origin)
			1.	Nursing Administrator or	REGISTERED NURSE (APRN)
	4.	Other Field Part-time
2. African American
	5.	Unemployed (less than		Assistant Administrator	ROLE
3. Native American
			2.	Consultant
		5 yrs)			1.	CRNA
4. Asian
			3.	Supervisor or Assistant
	6.	Unemployed (5 yrs or			2.	CNM
5. Hispanic
				Supervisor
		more)			3. CNS
6. Other (specify)
			4.	Educator/Instructor
	7.	Inactive			4.	CNP
____________
			5.	Head Nurse/Assistant
	EMPLOYER
				Head Nurse			Check here if you wish to only renew
	Name____________________		6.	General Duty or Staff
					as a RN without renewing your
			7.	Clinical Specialist
	_________________________				Mississippi APRN certification.
				(Masters Degree)

	City ______________________		8.	Nurse Practitioner
			9.	RNFA (Registered Nurse First
	State _____________________			Assistant)
			10. Other (Specify)_________
	County____________________

Since you last held an active Mississippi license, have you been disciplined by any disciplinary licensing board or agency or convicted of a felony or misdemeanor in any court of law (excluding speeding tickets), or are any charges currently pending against

you? YES NO

If the answer to the above question is “YES”, attach a detailed explanation and certified copies of all pertinent records, including

but not limited to, any and all court and/or regulatory agency records from the applicable state or jurisdiction. Allow additional time for “YES” answers to be reviewed.

Please check here if you allow us to disclose your email address to selected third parties. YES

By my signature below, I certify that the above information is correct.

Signature: _________________________________________ Date: _______________

Get Mississippi Nurse Renewal File

File Features

Fact Name	Details
Renewal Fees	Active: $100.00; Inactive: $25.00; APRN: $100.00; CSPA: $50.00.
Renewal Deadline	Licenses must be renewed by December 31, 2014, to avoid penalties.
Reinstatement Fees	After expiration, fees for reinstatement mirror renewal fees, plus additional charges.
Name Change Requirements	A fee of $25.00 and legal documentation must be submitted for a name change.
Multi-State Licensure	Nurses can practice in Compact states but must obtain new licensure if residency changes.

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