Mailing List Application Form

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Mailing List Application
Return to: Nevada State Board of Nursing, 5011 Meadowood Mall Way #300, Reno, NV 89502-6547
888-590-6726 (telephone), 775-688-2628 (fax), 88-0092597 (tax ID)
(775) 687-7707
•
Mailing lists consist of only the name and address of record of the license/certificate holder.
•
Each mailing list is provided for a specified purpose only and is a one-time use only list. The list
may not be resold or reused.
•
Mailing lists will not be provided for the purposes of verification of licensure or certification.
Please type or print clearly
Name of Person Requesting List
Name of Organization
Telephone Number
Fax Number
Email address
Mailing address
City
State
Zip
List will be used for:
Mailing lists are provided in ASCII text, comma-delimited format, and are provided via email, on diskette
(zipped if larger than 1.44 MB) or on CD. Please select your preferred method below:
Diskette
Email (You must provide email address above)
CD
Select
Type
License Type
Fees
Total Your Payment
Registered Nurse
$150.00
Licensed Practical Nurse
$75.00
Advanced Pract ice Registered Nurse
$30.00
Certified Registered Nurse Anesthetist
$30.00
Certified Nursing Assistant
$100.00
Special Programming
$350.00
TOTAL
$
Attach appropriate nonrefundable fee with application
If paying by credit card, please complete:
Choose one: Visa____ MasterCard___ Discover___ Card number___________________________ Exp. date_____
Name on card________________________________ Amount _____ Signature_____________________________
Disclaimer: While the Board believes the information to be reliable, human or mechanical error remains a possibility, as does delay in the
posting or updating of information. Therefore, the Board makes no guarantee as to the accuracy, completeness, timeliness, currency, the correct
sequencing of the information or to the suitability of the list for the purpose specified. Neither the Board, nor any of the sources of the
information, shall be responsible for any errors or omissions, or for the use or results obtained from the use of this information.
rev 4-2-07

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