Have you reviewed the SPE information in the link provided? *

Were you previously licensed as an LPN in another Canadian jurisdiction? *

Have you been charged with or convicted of a criminal offence: *

If yes, please select the following that apply to you. *

As an LPN, you must report any condition that significantly impairs or could impair your professional practice. This includes physical, mental, or emotional conditions, and substance use disorders. Examples of reportable conditions include: Severe depression Uncontrolled anxiety Substance addiction Neurological disorder Conditions that are temporary, well-managed, or do not affect safe nursing care (e.g., recent sprains, mild anxiety managed through therapy or control chronic conditions) do not require reporting. The Standards of Practice mandate reporting any medical condition that could hinder competent nursing duties. This transparency maintains professional integrity and ensures patient safety. In the last five (5) years, have you had any health conditions, including an addiction to drugs and/or alcohol that impacted your personal well-being or your ability to provide safe and effective patient care? *

I declare that all of the information on this form is current, correct and complete. *

I hereby certify that I am the person making the application for a Supervised Practice Experience (SPE) Program as a Licensed Practical Nurse in Saskatchewan and that all statements are true and complete in every respect. *

I understand that my application for assessment of eligibility and/or licensure is considered lapsed if required documentation is not received by the CLPNS office, and I have not obtained clinical placement within 6 months from my application date. I understand that after 6 months have lapsed I may be required to reapply. *

I acknowledge and agree that the CLPNS may immediately revoke, suspend or refuse licensure if any information contained in this form is inaccurate or incomplete. *

I acknowledge that the information contained in this form is collected and used for the purpose of assessing and approving applications, and or future renewals, or registration changes. *

I understand that LPNs are expected to provide care that is physically, psychologically, and culturally safe. I will promote inclusion, belonging, and environments that are free from racism and discrimination. *