Verification of Original Licensure form - Maryland Board of ...
[Pages:1]Verification of
Original Licensure
* Most States Charge A Fee to Verify Your Board Scores
Maryland Board of Nursing 4140 Patterson Avenue Baltimore, MD 21215-2254 410-585-1900
PART 1: To be completed by the applicant and forwarded to original state of licensure and all appropriate licensing boards.
Name (Last, First, Middle, Maiden)
Previous Name(s)
Current Street Address
City
State Zip
Date of Birth (MM/DD/YYYY)
Social Security Number
A
P Name as it appears on original license (Last, First, Middle, Maiden)
P
L I Original State of Licensure
Issue Date of Original License
C
A Current State of Licensure N
Issue Date of Current License
T
LIST ALL OTHER STATES OF LICENSURE
State: _____ License Number: _____________________________ Date Issued: _________
State: _____ License Number: _____________________________ Date Issued: _________
State: _____ License Number: _____________________________ Date Issued: _________
State: _____ License Number: _____________________________ Date Issued: _________
Nursing Education Program
Degree Granted
City of Program
State Date of Completion
Original License #
Type of License
RN LP/VN
Current License #
Type of License
RN LP/VN
I hereby authorize all identified Boards of Nursing to release my licensure data to the Maryland Board of Nursing
Signature: _____________________________________________
Date:
_____________________________________________
L PART 2: To be completed by licensing board and forwarded to the Maryland Board of Nursing.
I
C This is to certify that __________________________________ was issued License number ______________________ Date Issued: ___________
E
(Applicant Name)
to practice
Registered Nursing
N
Practical/Vocational Nursing
S E Licensed by:
Examination
Current License Status:
Active
Endorsement
Inactive
B O
Waiver
Lapsed
Expiration Date: _______________
A Has this license ever been encumbered (denied, revoked, suspended, surrendered, limited, or placed on probation)?
R
D Disciplinary action pending?
Yes
No
Please explain YES responses on reverse side.
Yes No
O Part 3: To be completed only by original state of licensure and forwarded to the Maryland Board of Nursing.
R Nursing Education Program Completed I
Approved by State?
Yes No
Graduated from :
H.S.
H.S. Equivalency
10th Grade
G Location (city/state) I N A
Graduation Date
STATE BOARD TEST POOL EXAMINATION Registered Nurse
Type of Nursing Program
DIP AD BSN LPN
LP/VN NCLEX-RN
NCLEX-LP/VN
L
Medical
Psychiatric
Obstetric
Surgical
Nursing of
Nursing
Nursing
Nursing
Nursing
Children
L
I C Score
E Series/Form
N
S E
Score
State/Provincial Constructed Exam __________
CNATS Exam
B
D
Other (please explain)
__________ __________
Number of times applicant wrote exam
Exam in English?
Yes
No
Took CGFNS?
Yes No
Dates:
_______________ _______________ _______________
_______________
SEAL
Signature _____________________________________
Title
_____________________________________
State
_________________ Date _______________
................
................
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