Application For Licensure As A Registered Nurse By Reciprocity Information And Instructions Page 8

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The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Division of Health Professions Licensure
Board of Registration in Nursing
VERIFICATION OF NURSE LICENSURE
*This verification will expire 6 months from the date of receipt by PCS.*
APPLICANT: COMPLETE THIS SECTION ONLY

,  RN 
L
I,
PN/LVN
License Number
,
am applying to the Massachusetts Board of Nursing for licensure by reciprocity. I hereby authorize you to
furnish to the Massachusetts Board of Nursing the information requested below.
This is the original state of issue? Yes
No
(Date)
(Signature)
(Maiden Name)
APPLICANT: DO NOT WRITE BELOW THIS LINE
Applicant Name as Appearing on Original License
Applicant Name as Appearing on Current License
NURSING EDUCATION
PROGRAM NAME AND LOCATION:
Board Approved: Yes
No
Language of
Classroom
Course
Clinical
Nursing Instruction: Instruction
Textbooks
Practice
Program:
Practical Nurse/Vocational Nurse
Registered Nurse
Withdrawn from RN program
Type:
Certificate
Diploma
Degree:
Associate
Baccalaureate
Entry Level Masters
Month/Year Graduated (or withdrawn, if applicable)
Length of Program
Applicant Registration Number
Date of Original Issue
Current Licensure Status:
Expiration Date
Method of Licensure (Check One): Examination
Waiver
Reciprocity
Type of Exam:
NCLEX
SBTPE
Exam Date
(If “Yes”, Provide A Certified Copy of All Related Documents.)
Has License Ever Been Disciplined? Yes
No
(If “Yes” Please Explain.)
Is Applicant Currently Under Investigation? Yes
No
I certify the above to be a true report for the above-named Nurse according to the records in this office.
Authorized Person
Signature:
Date:
Print Name:
Title:
Jurisdiction:
Affix Board Seal
Mail to:
Professional Credential Services
ATTN: MA Reciprocity Nursing
P.O. Box 198788
Nashville, TN 37219
Revised January 2015
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