Declaration Of Primary State Of Residence Form - South Carolina Board Of Nursing printable pdf download

Declaration Of Primary State Of Residence Form - South Carolina Board Of Nursing

DECLARATION OF PRIMARY STATE OF RESIDENCE

FOR PURPOSES OF THE NURSE LICENSURE COMPACT

Faxed copies will not be accepted.

Name: _____________________________________________________________________

Address: ___________________________________________________________________

City: ___________________________________ State: _________ Zip: ______________

(Is This A Change Of Address, Please Check:

)

Yes

License #: ________________ SSN * ________________ Date of Birth: ____/____/_____

In accordance with §40-33-1350 of the S.C. Code of Laws, I hereby declare the following as my primary

state of residence and that such constitutes my permanent and principal home for legal purposes.

Compact rules and regulations will require each nurse to declare in writing his/her primary state of

residence upon initial application and renewal of the nursing license. ‘“Primary state of residence” as

defined by the Compact means the “person’s declared fixed permanent and principal home for legal

purposes; domicile.” Proof of primary residence may include but is not limited to 1)

Driver's license with

a home address; 2) Voter registration card displaying a home address; 3) Federal income tax return

declaring the primary state of residence. 4) Military Form # 2058- state of legal residence certificate; or

5) W2 from US Government or any bureau, division or agency thereof indicating the declared state of

residence.

Please visit the National Council of State Boards of Nursing website ( ) for a

list of states that have implemented the Compact.

The Compact primary residence rule does not apply to military nurses or nurses in the federal

government, unless they are working outside of their military or government position.

I declare my primary state of residence is: ____________________________________________

I intend to primarily practice in the state of: ____________________________________________

I currently practice in the following states:

_______ _______ _______ _______ ________

I am in the military or federal government and I am currently licensed in ________________

(state). I do not intend to work outside of the military or federal government.

By the signature below, I attest to the accuracy of the information provided.

Signature: ___________________________________________ Date: ___________

Please return the completed Declaration Form in the enclosed envelope or to the S.C. Board of

Nursing, Post Office Box 12367, Columbia, SC 29211. Faxed copies are not accepted.

If you need more information, please visit our website:

* The disclosure of the social security number for identification purposes is authorized and mandated by

state and federal statutes. The social security number is not subject to disclosure as public information.

Declaration Of Primary State Of Residence Form - South Carolina Board Of Nursing