Reinstatement Request Form

Reinstatement Request Form
Pursuant to 16.12.1.9.J NMAC and 16.12.11.14 NMAC individuals have the right to petition the Board for reinstatement of their license or certificate after a disciplinary action by the Board. If your license is inactive or lapsed for any reason than other than a disciplinary action by the Board, you do not need to complete this form. The form below begins the formal request process. All responses are forwarded to the Executive Director of the agency.

Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Complaint number(s) associated with Board action resulting in revocation
Do you have current or pending discipline issued by any nursing regulatory body or board of nursing?*

YesNo
Jurisdiction
Do you have current or pending criminal investigations or convictions?*

YesNo
What is the nature of the investigation/conviction and from which county and state?
Are you a current or former participant in the New Mexico Board of Nursing Diversion Program?*

yes current participantyes participated within the last 5 yearsno never a participant or participated more than 5 years ago.
Upload official letter of petition for reinstatement of license/certificate.*

Cancelof
By digitally signing below, I attest that all the information provided in this webform is true, accurate, and complete to the best of my knowledge. I understand that any false or misleading information may result in consequences as determined by applicable laws and regulations. I acknowledge that the digital signature is my legally binding electronic signature for this document.
Signature*

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