Application For Licensure As A Registered Nurse By Reciprocity Information And Instructions Page 7
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8P.O. Box 198788
Nashville, TN 37219
APPLICATION FOR LICENSURE AS A REGISTERED NURSE BY RECIPROCITY
Payment Form
Two payment options are available: Money Order or Credit Card.
Applicant Name:
Social Security Number (Mandatory):
-
-
Fees are non-refundable and non-transferable.
Licensure by Reciprocity Application Fee: $275.00
Please check form of payment below:
Money Order (Please ensure the applicant’s name is on the payment)
If paying by Money Order, please make it payable to “PCS.”
Or
Credit Card
Authorized payment amount: $
Please check one:
Visa
MasterCard
Card Number:
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Exp:
/
Print name as it appears on account:
Authorized Signature:
Return this payment form with Application Form. DO NOT staple your payment to this form.
Note: This document will be shredded after it has been processed.
Revised January 2015
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