This form is for individuals who have a criminal conviction(s) on their record and are seeking a review by the SALPN to determine registration and licensure eligibility.

Who should complete this application?

1. Students enrolled in a Practical Nursing Program with an “unsatisfactory” criminal record and want their eligibility for registration and licensure with the SALPN determined before program completion.

2. LPNs registered and licensed in another jurisdiction with an “unsatisfactory” criminal record and want their eligibility for registration and licensure with the SALPN determined before they formally apply.

Please review the SALPN’s Criminal Record Legislative Interpretation and complete the following form.

The Criminal Record Assessment fee is $100.00.