Application For Licensure As A Registered Nurse By Reciprocity Information And Instructions (Page 6 of 8) in pdf

Application For Licensure As A Registered Nurse By Reciprocity Information And Instructions Page 6

ATTESTATION:

By signing this application for nurse licensure by reciprocity, I certify, under the

pains and penalties of perjury, that:



The information that I have provided in connection with this application is truthful and accurate;



I understand that the failure to provide truthful and accurate information may be grounds for the Board to

deny my nurse licensure in accordance with Massachusetts law and may effect my ability to obtain

licensure and/or practice nursing in this or any other jurisdiction in which I am currently licensed or may

seek licensure in the future;



I have read and understand the Board’s Licensure Policy 00-01: Determination of Good Moral Character

Compliance and the Determination of Good Moral Character Compliance Information Sheet;



I understand that this application will expire if the application is incomplete or if any requirements for nurse

licensure are not met within one (1) year from the date of the receipt of the application by PCS on behalf of

the Board. I also understand that fees are non-refundable and non-transferable; and



If I am granted nurse licensure by the Board, I will comply with M.G.L. c. 112, §§ 74 through 81C as well as

any other laws and regulations (including those at 244 CMR 3.00 through 9.00 related to licensure and practice).

STAPLE A

RECENT

2X2

Signature of Applicant

PASSPORT TYPE

SIGNED

COLOR

PHOTO HERE

Date

FACE ONLY

Mail to:

Professional Credential Services

ATTN: MA Reciprocity Nursing

P.O. Box 198788

Nashville, TN 37219

Revised January 2015

Page

Application For Licensure As A Registered Nurse By Reciprocity Information And Instructions Page 6