ALABAMA BOARD OF NURSING
ALABAMA BOARD OF NURSING
ANNUAL REPORT OF EMPLOYING AGENCIES
LICENSED NURSES
Name of Agency: _______________________________________________________________
Address: _____________________________________________________________________
_____________________________________________________________________________
Telephone: ________________________ County: ___________________________
|License Number |Employee Name (as shown on license card) |Expiration Date |
| | | |
_________________ _____________________________________
Date Signature
_____________________________________
Title
ABN 1/1999 (Use additional sheets as necessary)
................
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