RN Reactivation Applicant Teresa A. Hennessy

BUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS

P. O. Box 2649

Harrisburg, PA 17105-2649

APPLICANT INFORMATION

ADDRESS DETAILS

Street Address ** ****** ****** ***. #* SAYRE, PA 18840 City/State/Zip SAYRE PA 18840

County Bradford Country United States

CONTACT DETAILS

Phone number 570-***-**** Mobile Phone number 570-***-**** Primary Email

Address

*********@****.**.*** Secondary Email Address

PERSONAL INFORMATION

Last Name HENNESSY First Name TERESA

Middle

Name

A Suffix

Full Name TERESA A HENNESSY

SSN 2100 Date Of Birth 10/16/1965 Age 60 Gender FEMALE LEGAL QUESTIONS

Questions Answer Document

Uploaded

File Name

1 Have you completed a minimum of 30 hours of Board- approved continuing education within the last 2

years? To reactivate the license, you are required to complete at least 30 hours of Board-approved

continuing education within the past two years.

Y No

2 With the exception of the one you are currently

reactivating, do you hold, or have you ever held, a license, certificate, permit, registration or other authorization to practice a profession or occupation in any state or jurisdiction?

Y No

3

Please provide the profession and state or jurisdiction. RN-New York No

CHECKLIST ITEMS

Checklist name Status Submitted Date Expiration Date Application Pending Review 10/17/2025

Application Fee Completed 10/17/2025

Child Abuse CE Not Received 10/17/2025

Nursing- Registered Nurse- Application

RN281050L

Reactivation AA0006636080

CURRENT LICENSE INFORMATION

License No. RN281050L Profession Name Nursing

License Status Expired License Type Registered Nurse Expiration Date 10/31/2021

4 Since your initial application or last renewal,

whichever is later, have you had disciplinary action taken against a professional or occupational license, certificate, permit, registration or other authorization to practice a profession or occupation issued to you in any state or jurisdiction or have you agreed to

voluntary surrender in lieu of discipline?

N No

5 Is the action taken in PA? If yes, Certified copies are not required.

No

6

Please upload information:

No

7 Do you currently have any disciplinary charges

pending against your professional or occupational

license, certificate, permit or registration in any state or jurisdiction?

N No

8 Since your initial application or last renewal,

whichever is later, have you withdrawn an application for a professional or occupational license, certificate, permit or registration, had an application denied or refused, or for disciplinary reasons agreed not to apply or reapply for a professional or occupational license, certificate, permit or registration in any state or jurisdiction?

N No

9 Since your initial application or your last renewal, whichever is later, have you had provider privileges denied, revoked, suspended or restricted by a Medical Assistance agency, Medicare, third party payor or

another authority?

N No

10 Since your initial application or your last renewal, whichever is later, have you had practice privileges denied, revoked, suspended, or restricted by a

hospital or any health care facility?

N No

11 Since your initial application or your last renewal, whichever is later, have you been charged by a

hospital, university, or research facility with violating research protocols, falsifying research, or engaging in other research misconduct?

N No

12 Since your initial application or last renewal, whichever is later, are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would

otherwise adversely affect your ability to practice

(Nursing-Registered Nurse) in a competent, ethical, and professional manner?

N No

13 Have you engaged in or practiced in your profession in Pennsylvania since your license lapsed or since you placed it on inactive status?

No No

STANDARD QUESTIONS

Questions Answer

1 Are you submitting a name change with this reactivation? N 2 First Name

3 Middle Name

4 Last Name

5

You must submit a copy of a legal document verifying the name(s). The following are acceptable name change verification documents:

(1) A birth certificate.

(2) A marriage certificate (not a marriage license).

(3) Divorce decree.

(4) An official name change document issued by a court.

(5) A passport.

(6) A social security card.

(7) A Pennsylvania driver’s license or non-driver ID card.

(8) A driver’s license or official non-driver ID card issued by another state that complies with the federal REAL ID Act requirements (signified with a star on the front) 6 Are you submitting an address change with this reactivation? N 7 Please provide the address:

8 Are you a servicemember, veteran, or military spouse? N 9 Please upload documentation demonstrating your status as a Servicemember, veteran or military spouse.

Licenses/Certificates/Permits/Registrations in Any State/Jurisdiction Profession State/Jurisdiction

RN New York

PA VETERANS REGISTRY

Questions Answer

1 Have you served in the U.S. Armed Forces? N

2 Thank you for your service. Would you like to register with the PA Veterans Registry? The PA Veterans Registry provides veterans with information about federal, state and local benefits, programs and services that are available to Pennsylvania veterans and links veterans with resources that can provide assistance. Registration is quick and easy, and provides the Department of Military and Veterans Affairs (DMVA) with a way to contact you regarding the benefits and services you may be eligible for. If you check “Yes,” you will receive an email with instructions to assist you in registering.

CONFIRMATION

Any fees paid are non refundable. ( 10/17/2025 19:31:36 ) ACKNOWLEDGEMENT OF DUTY TO SELF-REPORT DISCIPLINARY CONDUCT AND CERTAIN CRIMINAL ACTIVITY

I hereby acknowledge that in addition to any existing reporting requirement required by a specific board or commission, I am REQUIRED pursuant to Act 6 of 2018 to NOTIFY the Bureau of Professional and Occupational Affairs WITHIN 30 DAYS of the occurrence of any of the following:

(1) A disciplinary action taken against me by a licensing board or agency in another jurisdiction;

(2) A finding or verdict of guilt, an admission of guilt, a plea of nolo contendere, probation without verdict, a disposition in lieu of trial or an Accelerated Rehabilitative Disposition (ARD) of any felony or misdemeanor offense in a criminal proceeding. I further acknowledge that failure to comply with these mandatory reporting requirements may subject me to disciplinary action by the Board. I acknowledge my understanding that to self-report a disciplinary action or criminal matter as set forth above, I may log in to the Pennsylvania Licensing System (PALS) at www.pals.pa.gov and select “Mandatory Reporting by Licensee” under the heading “Your Licenses.”

( 10/17/2025 19:31:36 )

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