Criminal Record Assessment Criminal Record Assessment 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. First Name * Last Name * Date of Birth * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Contact Phone Number * Email Address * Nursing Program Expected Completion Date, if Applicable Upload your criminal record check and any other requested documentation * Drop a file here or click to upload Choose File Maximum upload size: 268.44MB The Criminal Record Assessment fee is $100.00. Card Type VISA MasterCard Credit Card Credit Card Credit Card Credit Card Month 1 2 3 4 5 6 7 8 9 10 11 12 Credit Card Year 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 Credit Card reCAPTCHA If you are human, leave this field blank. Submit