Foreign-trained nurses who want to practice in the United States face a multi-step licensing process that typically takes 9–18 months from start to finish. The pathway involves credential evaluation, English language testing, state board eligibility review, and the NCLEX-RN exam. Each step has its own application, fee, and processing time. Understanding the full sequence upfront prevents delays caused by missing steps or applying to the wrong state board.
The four-stage pathway
Every international nurse follows the same general sequence, though the specifics vary by state:
- Credential evaluation – An approved organization reviews your nursing education and verifies it’s equivalent to US nursing standards
- State board eligibility – Your target state board of nursing reviews your credentials and determines whether you’re eligible to sit for the NCLEX
- NCLEX-RN – You register, receive authorization to test, and pass the exam
- State licensure – The state issues your RN license; you can then endorse to other states
Stage 1: Credential evaluation
Every state board requires an independent evaluation of foreign nursing education before it will review your application. The primary organization for nurses is CGFNS International (Commission on Graduates of Foreign Nursing Schools), which now operates as TruMerit.
The CGFNS Credentials Evaluation Service (CES)
The CES report verifies that your nursing education – theory and clinical hours – is comparable to US requirements. CGFNS contacts your nursing school directly to obtain transcripts and verifies your license in your home country.
- Cost: roughly $350–$500 for the professional report, depending on add-ons (check TruMerit’s current fee schedule before ordering)
- Processing time: 4–6 months, sometimes longer for countries with slower institutional response times
- Documents required: Official transcripts from your nursing school (sent directly from the institution), verification of your home country nursing license, and your nursing school’s description of the curriculum
TruMerit also runs the Certification Program, which bundles a credentials review, an English test and the TruMerit Qualifying Exam of nursing knowledge. A minority of boards accept the Certification Program as one option among several (Illinois, for example, accepts it alongside the CES report or a VisaScreen verification letter), but it is rarely the only route. Confirm what your target state lists before paying for it.
What popular first-licensure states ask for
This is one of the most important variables in choosing your first licensure state. TruMerit publishes the service each board requires for RN initial licensure:
| State | Evaluation TruMerit lists for RN initial licensure | Notes |
|---|---|---|
| California | CES Professional Report | The BRN also accepts reports from IERF, its other approved evaluator; the BRN does not accept foreign transcripts sent directly |
| Texas, Florida, Georgia | CES Professional Report | Georgia requires one active foreign license at the time the CES report is issued |
| New York | Credentials Verification Service for New York State (CVS) | A separate, New York-specific product; ordering a standard CES report instead will not satisfy NYSED |
| Illinois | Certification Program, CES Professional Report, or VisaScreen verification letter (any one) | Plus English proficiency results |
No state lets an internationally educated nurse skip the evaluation step entirely, so budget the time and fee for it whichever board you choose. The real differences between states lie in board processing speed, English-test thresholds and Social Security Number policy (see below).
Stage 2: English language requirements
Most state boards require proof of English proficiency if your nursing education was not conducted in English. Each board sets its own accepted exams and minimum scores. If you are immigrating on an occupational visa, you must also meet the federal standard for VisaScreen, which is set by the Department of Health and Human Services (HRSA) and is often the stricter of the two.
Federal VisaScreen minimums for registered nurses (tests taken on or after May 12, 2026)
| Exam | Minimum for RNs | Notes |
|---|---|---|
| IELTS Academic | 6.5 overall, 7.0 speaking | Unchanged in the 2026 update |
| TOEFL iBT | 4.5 overall and 4.5 speaking; 3.5 in reading, listening and writing | Uses the revised TOEFL 1–6 band scale |
| OET (Occupational English Test) | Speaking 360, writing 350, reading 340, listening 320 | Raised in 2026 from the former 350 speaking / 300 other sections |
| PTE Academic | Speaking 76; 62 in reading, writing and listening | Raised in 2026 from the former 50-point section minimums |
If you sat an approved exam before May 12, 2026, the previous HRSA scores still apply to your VisaScreen application. Scores are generally valid for two years, and TruMerit does not accept remotely proctored tests for VisaScreen.
OET is designed for healthcare professionals and uses medical scenarios in its reading, writing, listening, and speaking components. Many internationally educated nurses find it more relevant to their work context, though preparation materials are less widely available than for IELTS or TOEFL.
Check your target state’s board website for its exact thresholds. Some boards waive their own English test when the applicant’s nursing program was taught in English, which often helps graduates from the Philippines, India, Nigeria and Jamaica at the licensure stage. The federal VisaScreen exemption is much narrower: it covers only professional education completed in English in the United Kingdom, Australia, Canada (except Quebec), New Zealand, Ireland or the United States. A nurse educated in English in the Philippines or India who is immigrating will still need a passing test score for VisaScreen.
Stage 3: Social Security Number requirement
Many states ask for a Social Security Number (SSN) on a nursing license application. For international nurses who don’t yet have work authorization in the US, this can create a sequencing problem.
Alternatives exist in some states: California’s BRN has accepted an Individual Taxpayer Identification Number (ITIN) in place of an SSN since April 2015 (Business and Professions Code section 30). Other boards accept a signed statement that you don’t have an SSN and will provide it once issued. Policies change, so confirm your target board’s current rule before applying.
If you’re applying for licensure from outside the US before immigrating, research your target state’s SSN policy carefully. Some internationally educated nurses choose their first licensure state based on this factor alone.
Stage 4: NCLEX-RN registration and authorization to test
Once your state board approves your eligibility, you register with Pearson VUE, the testing administrator for NCLEX.
Steps after board approval
- Register with Pearson VUE at pearsonvue.com/nclex – the registration fee is $200. If you test at a center outside the US, Canada or Australia, Pearson VUE adds a $150 international scheduling fee plus any local VAT
- Receive your ATT (Authorization to Test) letter by email – typically arrives within 1–2 weeks of Pearson VUE receiving your eligibility confirmation from the board
- Schedule your exam – your board sets the ATT validity period (90 days is typical); schedule within that window
- Test at a Pearson VUE testing center – the NCLEX is now the Next Generation NCLEX (NGN) format, which includes case studies and clinical judgment questions. You will see a minimum of 85 and a maximum of 150 items, with up to five hours of testing time. The exam ends when the computer determines with 95% confidence whether you’ve passed or failed.
Results: in most jurisdictions you can buy unofficial results through the NCLEX Quick Results service for $7.95, available two business days after the exam. Official results come from your board of nursing, usually within about six weeks.
For NCLEX preparation strategies, see the NCLEX study tips guide and the what happens if you fail the NCLEX guide.
Visa considerations: VisaScreen and retrogression
If you’re immigrating to the US to practice nursing (rather than being already present on another visa), the immigration process adds significant complexity.
VisaScreen certificate
Federal law (INA section 212(a)(5)(C) and 8 CFR 212.15) requires a health care worker certificate for foreign-educated nurses seeking a permanent or temporary occupational visa, including TN status. TruMerit (CGFNS) issues the VisaScreen certificate after verifying education, licensure and English proficiency. It is separate from the CES report, though some documentation overlaps. Some RNs who hold an unrestricted US license and passed the NCLEX may qualify for the shorter 212(r) Certified Statement instead.
Retrogression
The EB-3 visa category (skilled workers, professionals, and other workers) – which most foreign nurses use – is subject to annual numerical limits. When demand exceeds supply in a given country, visa dates “retrogress,” meaning applicants from oversubscribed countries (primarily Philippines and India) may wait years for a visa number to become available. Check the Visa Bulletin from the US Department of State for current priority dates before planning your timeline.
Nursing on a different visa
Some internationally educated nurses enter the US on an H-4 (spouse), F-1 (student), or other visa, then adjust status after licensure. This avoids the EB-3 retrogression issue but requires separate immigration analysis.
License by endorsement
Once you have an RN license in any US state, moving to another state is straightforward through nursing license by endorsement. You apply to the new state’s board, pay the fee, and your existing licensure record is reviewed rather than your full international credentials. This is why your first licensure state matters less than it seems: once you hold one US license, endorsement opens up the other states.
Realistic timeline overview
| Stage | Timeframe | Depends on |
|---|---|---|
| CGFNS CES evaluation | 4–6 months | Institution response speed in home country |
| English language test prep and sitting | 1–3 months | Baseline proficiency |
| State board application review | 2–6 months | State board processing backlog |
| Pearson VUE ATT and scheduling | 1–4 weeks | Board confirmation speed |
| NCLEX preparation | 2–4 months (varies) | Prior exam prep, time available |
| Total (full pathway) | 9–18 months | Combination of above |
Starting from outside the US with no steps completed: plan for 12–18 months to licensure. Already in the US with valid English scores and CGFNS in progress: 6–12 months is realistic.
WES vs CGFNS
Some internationally educated nurses ask whether WES (World Education Services) can substitute for CGFNS. WES evaluates academic credentials broadly, but boards of nursing generally do not accept it for RN licensure, because they need a nursing-specific review of theory and clinical hours. Each board names its own approved evaluators: CGFNS (now operating as TruMerit) is accepted almost everywhere, and some boards approve others, such as IERF in California. Nursys is not a credential evaluator – it is the NCSBN licensure verification database, used to confirm an existing US license rather than to assess foreign education. Check your board’s approved-evaluator list before ordering, because submitting a report from an unapproved service will delay or invalidate your application.
IEN-specific NCLEX preparation
The content on NCLEX is the same for internationally educated nurses (IENs) as for US graduates – but the test requires US-specific clinical judgment, including familiarity with:
- US medication names (generic and brand names differ from country to country)
- HIPAA, informed consent, and patient rights frameworks
- The US scope of practice distinctions (what RNs do vs. what is delegated to LPNs or CNAs)
- The Next Generation NCLEX clinical judgment model, which emphasizes recognizing cues, forming hypotheses, and evaluating outcomes
IEN-specific prep materials from ATI and Hurst Review include modules on US nursing practice context. Use these alongside standard NCLEX review.
Frequently asked questions
Do I need to pass the NCLEX if I already have a nursing license from another country? Yes, with no exceptions. NCLEX is required for RN licensure in all 50 US states and US territories, regardless of your home country license, experience, or education level.
Can I apply to multiple states at once to speed up the process? You can – but each state charges its own application fee (commonly $100–$300 or more for examination applicants) and has its own processing timeline. Many IENs apply to one strategically chosen state first rather than paying multiple fees. Once licensed in one state, endorsement to others is faster.
What if CGFNS determines my education isn’t equivalent to US nursing standards? CGFNS issues a CES report indicating deficiencies. You can complete additional coursework – typically specific theory or clinical hours – to address gaps, then reapply. The most common deficiency is insufficient clinical hours in specific practice areas.
Is the NCLEX harder for international nurses? The exam content is identical. Pass rates for IENs are lower than for US-educated nurses. In 2025, 47.3% of first-time internationally educated candidates passed the NCLEX-RN, against 86.7% of first-time US-educated candidates (NCSBN), a gap driven largely by unfamiliarity with US nursing practice context and the clinical judgment model. Targeted preparation that addresses this gap significantly improves outcomes.
Can I work as a nurse in the US while my NCLEX application is pending? Generally no – you need an active RN license to work as an RN. Some states allow a graduate nurse (GN) permit that lets you work under supervision while awaiting NCLEX results, but this typically requires prior completion of a US nursing program. Your best option while waiting may be CNA or patient care technician work.
For more detail on what state licensure involves after the NCLEX, see the nursing license guide and the RN-to-BSN pathway if you’re considering advancing your education once licensed.
References
- National Council of State Boards of Nursing, “2025 NCLEX Examination Statistics,” Research Brief Volume 96, June 2026 (Table 1: first-time internationally educated 47.3%, first-time US-educated 86.7%).
- National Council of State Boards of Nursing, “NCLEX Pass Rates,” NCSBN, 2025.
- TruMerit (CGFNS International), “Select Your Service by U.S. State” – RN initial licensure requirements for California, Texas, Florida, Georgia, New York and Illinois, accessed September 2026.
- TruMerit (CGFNS International), “VisaScreen: Visa Credentials Assessment” – English proficiency requirements and exemptions, accessed September 2026.
- National Council of State Boards of Nursing, “Next Generation NCLEX (NGN): Clinical Judgment Measurement Model,” NCSBN, 2024.
- NCSBN, “Fees & Payment” and “Quick Results,” nclex.com, accessed September 2026.
- U.S. Department of State, Bureau of Consular Affairs, “Visa Bulletin: Employment-Based Immigrant Visa Priority Dates,” 2025.
- U.S. Citizenship and Immigration Services, “Employment-Based Immigration: Third Preference EB-3,” USCIS, 2025.
- U.S. Citizenship and Immigration Services, “Health Care Worker Certification,” USCIS (8 CFR 212.15).
- California Board of Registered Nursing, examination application instructions (SSN/ITIN disclosure under Business and Professions Code section 30), rn.ca.gov.