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Date Submitted: 09/26/2012 07:32 AM
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
Louise R. Baile y, MEd, RN, Executive Office r
VERIFICATION OF LICENSE
1.
2.
Send this form to the State Board of Nursing where you have a current and active license. The board of nursing may require a processing fee.
If you are licensed as an RN in a state that is a member of the Nursys verification system, visit www.nursys.com to complete the online verification
request application process.
INTERNATIONAL GRADUATES: Send form to the state of current license. If you took the examination in a different state, make a copy
of this form and send the form to that state also.
PART I: To be completed by APPLICANT and forwarded to appropriate licensing boards.
Name: (Last, First, Middle)
Previous Names: (Including Maiden)
Current Street Address of Record:
City:
Name as it Appeared on Original License: (Last, First, Middle)
State:
Date of Birth: (Month/Day/Year)
Zip Code:
Social Security Number:
State of Current Licensure:
Issue Date of Current License:
Current License Number:
State of Original Licensure:
Issue Date of Original License:
Original License Number:
I hereby authorize all identified Boards of Nursing to release my licensure data to the California Board of Registered Nursing.
Signature: _______________________________________________________________________ Date: ______________________
PART II: To be completed by licensing board and sent to the California Board of Registered Nursing listed at the top of this form.
This is to certify that this applicant was issued a license number to practice as a registered nurse:
Applicant Name: _______________________________________________________
Date Issued: ____________________
License Number: ____________________
Expiration Date: _________________
Licensed by:
Endorsement
Examination
Waiver
Current Licensure...