Medical or Family Medical Waiver forms
Family Medical leave Exemption form.pdf
Medical Waiver form.pdf
If you have a lapsed license choose the blank work attestation based on the year your licensed lapsed/expired below. If it is not listed here then call the board 304-558-3572.
Blank Work Attestation July 1st 2025.pdf
Blank work attestation July 1st 2024.pdf
Blank Work Attestation July 1st 2023.pdf
Blank Work Attestation July 1st 2022.pdf
Blank work attestation July 1st 2021.pdf
Blank Work Attestation July 1st 2020.pdf
Blank work attestation July 1st 2019.pdf
Blank Work Attestation July 1st 2018.pdf
Verification of employment (VOE) Forms: MUST have 400 hours every 2 years by even year: Your employer can fax it to the board 304-558-4367 or email lpn.board@wv.gov directly on their letterhead with the dates and hours on it. If the nurse uploads verification form it must be notarized.
90 DAY LIMITED MEMO.pdf
VOE 90-day Limited license.pdf
You will need to choose the verification of employment file below that correlates to your Audit Dates from message center or Dates you are reinstating
VOE 2024 to 2026.pdf
VOE 2022 to 2024.pdf
VOE 2020 to 2022.pdf
VOE 2018 to 2020.pdf
VOE 2016 to 2018.pdf
VOE 2014 to 2016.pdf
VOE 2012 to 2014.pdf
VOE 2010 to 2012.pdf
Background Check Form
Background check form.pdf