Cali Verification

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Date Submitted: 09/26/2012 07:32 AM

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PO Box 944210, Sacramento, CA 94244-2100

P (916) 322-3350 F (916) 574-8637 |

Louise R. Baile y, MEd, RN, Executive Office r




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 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:


Name as it Appeared on Original License: (Last, First, Middle)


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:




Current Licensure...