Affidavit Of Graduation For Graduates In The Usa And Us Territories Form - Texas Board Of Nursing
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Texas Board of Nursing
Rcd Date:
333 Guadalupe, Ste. 3-460, Austin, TX 78701-3944
Phone: 512-305-7400 -- Web Site:
Affidavit of Graduation for Graduates in the USA and US Territories (RN Candidates)
This portion of the application must be completed by the Dean/Director of the Nursing Program only. The signature of other
persons such as associate deans, program coordinators, or faculty members will not be accepted unless the Board has received
official notification from the governing institution’s administration that another registered nurse on the faculty has been given the
authority to sign for the dean/director, the length of time that the signature authority is valid, and a sample of the authorized
person’s signature.
This affidavit verifies that the applicant named below successfully completed all requirements for completion of graduation from
an accredited professional nursing program. Please note, this portion of the application cannot be notarized prior to the
date of completion/graduation date.
I hereby verify_______________________________________________________________________________________
First Name
Middle Name/Maiden Name
Last Name
Social Security Number:_______-______-________entered the _______________________________________________
Name of School of Nursing
located in____________________________________________________ on the date of _______/______/__________
City
State
Enrollment Date (month/day/year)
and has completed requirements for graduation on the date of ________/_________/_________.
Graduation Date (month/day/year)
Program Code: ______ - ___________
Was this program conducted in English?
[
] YES
[
] NO
The applicant received:
[ ] Diploma in Nursing
[ ] Associate Degree
[ ] Baccalaureate Degree
[ ] Masters Degree
[ ] Has met BSN requirements enroute to MSN
[ ] Has met requirements for repeating a nursing program
NOTE: DEAN/DIRECTOR MUST SIGN THE AFFIDAVIT OF GRADUATION AFTER THE APPLICANT HAS
COMPLETED ALL REQUIREMENTS FOR GRADUATION.
I am the Dean/Director for the program listed above and attest that the factual statements contained in the information
provided on this affidavit are within my personal knowledge and are true and correct. Furthermore, I acknowledge this is a
legal document and understand that it is a violation of the 22 Texas Administrative Code, §§ 217.12 (6)(H) and the Penal
Code, sec 37.10, to submit a false statement to a government agency.
Name of Dean/Director
(School Seal)
Signature of Dean/Director
Texas Board of Nursing
Affidavit of Graduation
Rev 10/2007
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