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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