Change of Address Form - Maryland Board of Nursing
STATE OF MARYLAND
MARYLAND BOARD OF NURSING 4140 PATTERSON AVENUE
BALTIMORE, MARYLAND 21215-2254
(410) 585-1900 (410) 358-3530 FAX (410) 585-1978 AUTOMATED VERIFICATION
1-888-202-9861 TOLL FREE
CHANGE OF ADDRESS FORM FOR LICENSEES AND CERTIFICATE HOLDERS
PART I: Licensee/Certificate-Holder Information Full Name:__________________________________ License/Certificate No(s).:__________________________
E-mail address: ______________________________ Phone Number:__________________________________
Business Address:
PART II: Old Address(es)
_____________________________________________________________________________ Street Address
_____________________________________________________________________________
City
County
State
Zip Code
Home Address:
_____________________________________________________________________________ Street Address/Apartment No.
_____________________________________________________________________________
City
County
State
Zip Code
PART III: New Address(es) Business Add ress: This address is your public address of record and will be made available to the public in response to a Maryland Public Information Act request for your licensure or certification records.
_____________________________________________________________________________ Street Address
_____________________________________________________________________________
City
County
State
Zip Code
Home Address: This address will be used for Board mailings only. However, please be advised that if you do not provide a business address, the Board is required to disclose your home address in response to a Maryland Public Information Act request for your licensure or certification records.
_____________________________________________________________________________ Street Address/Apartment No.
_____________________________________________________________________________
City
County
State
Zip Code
*If you are a registered nur se or licensed practical nurse an d have m oved to or from Maryland, you also must complete a Declaration of Primary State of Residence form.
_____________________________________________________ Signature
__________________ Date
Rev. 5/2016
TDD FOR DISABLED MARYLAND RELAY SERVICE 1-800-735-2258
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