Form 08-4067a - Verification Of Nursing Employment For Reinstatement Of Nursing License
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1ALASKA BOARD OF NURSING
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
STATE OFFICE BUILDING
TH
333 WILLOUGHBY AVENUE, 9
FLOOR
P.O. BOX 110806, JUNEAU, ALASKA 99811-0806
Fax (907) 465-2974
E-mail: license@dced.state.ak.us
If your last name begins with A – K, contact (907) 465-2544
If your last name begins with L – Z, contact (907) 465-2648
VERIFICATION OF NURSING EMPLOYMENT
FOR REINSTATEMENT OF NURSING LICENSE
APPLICANT: Complete only the top portion of this form. Mail to your most recent employer where you worked in a nursing
capacity prior to working in Alaska (Nursing Service Director, Personnel Director, Human Resources Development, etc.).
PLEASE PRINT
I,
,
Last Name
(First)
(MI)
(Former)
am applying for reinstatement of my nursing license in Alaska, and I hereby authorize you to release information as required on
this form to the Alaska Board of Nursing.
o
o
I worked as a (check one):
Registered Nurse
OR
Practical/Vocational Nurse
Signature:
Social Security Number:
Address:
Date:
Employment Dates: From:
To:
EMPLOYER: Please complete this form as completely and thoroughly as your state laws allow and return to the address listed
above. Thank you for your cooperation.
1.
Employer’s Position/Title:
o
o
Did the position require employee to hold a current RN/LPN license?
Yes
No
If the position held by the nurse does not require a nursing license, please provide a copy of the position description.
2.
Dates of Employment: From:
To:
o
o
Applicant worked a minimum of 320 hours during this period?
Yes
No
3.
Clinical Service (Pediatric, Medical, etc.):
4.
Your Rating of Employee’s Ability in Nursing:
5.
Would reemployment be favorably considered?
6.
Other comments:
Signature:
Title:
Agency:
Date:
Mailing Address:
Street
City
State
Zip Code
Telephone No.
+
PLEASE RETURN COMPLETED FORM DIRECTLY TO THE BOARD OF NURSING AT THE ABOVE ADDRESS.
08-4067a (Rev. 8/00)
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