Form 08-4067b - Volunteer Professional Activities Verification
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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
VOLUNTEER PROFESSIONAL ACTIVITIES VERIFICATION
APPLICANT: If your license has lapsed less than five years and you have provided professional activities, complete the top
portion of this form and mail it to the organization/agency where the activities were performed. This is for consideration of having
met one of the three methods required for continued competency.
I,
, am applying for reinstatement of my license
to practice as a registered or as practical nurse and hereby authorize you to release information as required on this form.
Name:
Social Security No.
Address:
Dates of Professional Activities:
:
Signature:
From
To:
Bottom portion to be completed by organization/agency where activities were performed.
“Professional Activities” means activities that use nursing knowledge and that contribute
to the health of individuals or the community.
AGENCY: Please complete the remaining sections of this form and return to the address listed above.
This is to verify that
performed
(Name of Nurse)
(Number)
hours of professional activities for
(Organization)
at
(Mailing Address)
The nature of the activity was
and was completed during
,
.
(Month)
(Year)
Verified by:
Date:
(Signature)
(Title/Position)
+
Please return completed form directly to the Board of Nursing at the above address.
THANK YOU FOR YOUR COOPERATION.
08-4067b (Rev. 8/00)
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