Multi-State Licensure Privilege Notification Form - South Carolina Department Of Labor, Board Of Nursing
ADVERTISEMENT
1
2SOUTH CAROLINA DEPARTMENT OF LABOR, LICENSING & REGULATION
BOARD OF NURSING
110 Centerview Drive, Suite 202, Post Office Box 12367
Columbia, SC 29211-2367
MULTI-STATE LICENSURE PRIVILEGE NOTIFICATION FORM
T
S
C
C
S
O BE COMPLETED BY A NURSE WORKING IN
OUTH
AROLINA ON A LICENSE FROM ANOTHER
OMPACT
TATE
Please complete, sign, date and return to the address listed above the following information as required in S.C. Code,
Section 40-33-1315(D)(3). This information will be used to send you Board information, i.e. newsletters and include you
in the workforce studies done to determine the nursing needs in the state.
Name_____________________________________________________________________________________________
*Social Security #___________________________ Birth date ______/_____/______
Sex:
Female
Male
Race
(
)
American Indian
African American
Caucasian
Hispanic
Oriental/Asian
Other
for statistical purposes only
LPN
RN
State of Licensure____________ License No. ________________ Expiration Date________________
State of Residence
Address _____________________________________________________________________________Apt #__________________
City______________________________________________________State__________________Zip_________________________
Telephone____________________________________________E-mail_________________________________________________
SC Address __________________________________________________________________________Apt #__________________
City______________________________________________________State__________________Zip_________________________
Dates of approximate Length
Telephone______________________E-mail__________________________________of stay in SC: From__________To_________
Primary place of employment in South Carolina
Employer Name____________________________________________________________________________________
Place of
Approximate Length
Employment in SC____________________________________ of Stay in SC ______________Telephone____________________
City _________________________________________ County _____________________________State____________
Zip Code __________________Employers Telephone No.(______)__________________Hrs per Week _____________
Secondary place of employment in South Carolina
Employer Name____________________________________________________________________________________
City _________________________________________ County _____________________________ State ___________
Zip Code __________________Employers Telephone No.(______)__________________Hrs per Week _____________
1.
Indicate all degrees awarded.
Diploma School of Nursing
Doctorate Degree -
Nursing
Other
___________________________________________
___________________________________________
01
08
Name of School
State
Yr. Grad.
Name of School
State
Yr. Grad.
Associate Degree in Nursing
Baccalaureate Degree other than Nursing
___________________________________________
___________________________________________
02
11
Name of School
State
Yr. Grad.
Specify Major
Baccalaureate Degree in Nursing
Masters Degree other than Nursing
___________________________________________
___________________________________________
03
12
Name of School
State
Yr. Grad.
Specify Major
Masters Degree in Nursing
Nurse Practitioner Certificate Program
___________________________________________
___________________________________________
05
06
Name of School
State
Yr. Grad.
Name of School
State
Yr. Grad.
(Page 1 of 2)
Revised 7/21/06
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal