Endorsement Form - Nevada State Board Of Nursing printable pdf download

Nevada State Board of

URSING

Endorsement Form

NOTE: Send this form to the state in which you were originally licensed by examination. Before mailing the form, you will need to

contact that state board to determine the fee required for this service. If your state is enrolled in Nursys, you must submit a form online at

Part One: To Be Completed By Applicant

Applicant Name: _______________________________________________________ License Number: ________________

Other Names Licensed Under: ___________________________________________________________________________

Street Address: _______________________________________________________________________________________

City: _____________________________________________ State: ________________ Zip: _________________________

Social Security Number: ___________________________________ Date of Birth: _________________________________

I am requesting licensure in the State of Nevada as:

LPN

OTHER

Signature of Applicant _________________________________________________________________________________

Part Two: To Be Completed By Original State Of Licensure Board

Applicant's Name:_____________________________________________________________________________________

License Type:

LPN

OTHER

License Number:______________ Status:____________________

Original Date of Licensure: ____________________________ Expiration Date :__________________________________

Licensed By Examination

: Type:__________________ Date: __________________NCLEX Score:____________

SBTPE Scores: Medical __________ Surgical _________ Obstetric ________ Pediatric _________ Psychiatric _________

Licensed by Endorsement

(from which state): ________________________________________________________

Licensed by Waiver

(please explain): _________________________________________________________________

Name of Education Program completed: ___________________________________________________________________

City/State: ___________________________ Degree Awarded: _________________ Graduation Date: _______________

Disciplinary Information

: Has license, registration, or certification ever been denied, revoked, suspended, reprimanded,

fined, surrendered, restricted, limited, or placed on probation: Yes __________ No: ________ (If yes, please provide copies

of all petitions, orders, etc)

Signature: ___________________________________________ Title: __________________________________________

Board of Nursing: ___________________________________________________ Date: ____________________________

(Seal)

5011 Meadowood Mall Way, Suite 300, Reno, NV 89502-6576 (phone) 775-687-7700 (fax) 775-687-7707

rev. 11-21-13

4220 S. Maryland Pkwy., Suite 300, Las Vegas, NV 89119-7524 (phone) 702-486-5800 (fax) 702-486-5803

* 888-590-6726 * nursingboard@nsbn.state.nv.us

Endorsement Form - Nevada State Board Of Nursing