Form 08-4016 - Application For Registered Nurse By Endorsement

Form 08-4016 - Application For Registered Nurse By Endorsement - 2000 Page 3

All information submitted with this application is public information unless required to be confidential by state

or federal law. If additional information of a confidential nature is required, you will be notified in writing.

NURSING-RELATED EMPLOYMENT HISTORY: List employment for immediate past five years and list most

current employer first:

Dates

Name of Employer

Type of Work

From

Address:

I HEREBY CERTIFY and declare that I am the person referred to in the foregoing application and that the information

contained in this application is true and correct to the best of my knowledge. I further certify that all credentials supplied

by me are true and correct. I understand that any false information or falsification of credentials may result in failure to

obtain a license to practice nursing in the State of Alaska.

SIGN HERE

Signature of Applicant

(NOTARY SEAL)

SUBSCRIBED AND SWORN before me, a Notary Public in and

for the State of

this

day of

NOTARY

Signature of Notary Public

My Commission Expires:

WARNING: The Alaska Board of Nursing may deny, suspend, or revoke the license of a person who has

obtained or attempted to obtain a license to practice nursing by fraud or deceit. The person may also be

subject to criminal charge for perjury or unsworn falsification. (AS 11.56.210 and AS 11.56.230)

08-4016 (Rev. 8/00)

Form 08-4016 - Application For Registered Nurse By Endorsement - 2000 Page 3