Texas Board Of Nursing Verification Of Registered Nurse Licensure Form
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1TEXAS BOARD OF NURSING
333 Guadalupe, Ste. 3-460, Austin, Texas 78701
TEXAS BOARD OF NURSING VERIFICATION OF REGISTERED NURSE LICENSURE FORM
I. APPLICANT
To be completed by the applicant and forwarded to original state/province of licensure and ALL appropriate licensing boards.
Name (Last, First, Middle, Maiden)
Previous Name(s)
Current Address
City
State
Zip
Date of Birth (mo/day/yr)
Social Security Number
Basic Nursing Education Program -Type of Basic Nursing Program
[ ] DIP
[ ] ADN
[ ] BSN
[ ] OTHER
Name as appears on original license (Last,First,Middle,Maiden)
City of Program
State/Province
Date of Completion
Original State of Licensure
Issue date of Original Licensure
Original License Number
II. LICENSING BOARDS: To be completed by licensing board(s) (other than original state/province of licensure) where you hold RN licensure and forward
(ENDORSEMENT)
to the Texas Board of Nursing
This is to certify that __________________________________ was issued RN license number _______________________ Date Issued____________________
(Applicant)
Current Licensure Status:
[ ] Active
[ ] Inactive
[ ] Lapsed
Expiration Date:_________________________
Has license ever been encumbered (denied, revoked, suspended, surrendered, limited, placed on probation)?
**[ ] YES
[ ] NO
** If yes, please send certified copies of Board actions.
III. ORIGINAL LICENSING BOARD: To be completed only by original state of licensure and forwarded to the Texas Board of Nursing
(EXAMINATION)
Basic Nursing Education Program Completed
Approved by State/Province/Territory?
[ ] YES
[ ] NO
Location (city/state/province)
Graduation Date
Type of Basic Nursing Program
[ ] DIP [ ] ADN [ ] BSN
[
] Other____________________________
STATE BOARD TEST POOL EXAMINATION FOR REGISTERED NURSES
NCLEX-RN®
CNATSE
Medical
Psychiatric
Obstetric
Surgical
Nursing
Comprehensive Exam
Comprehensive Exam
Nursing
Nursing
Nursing
Nursing
of
Children
Score
Series/
Form#
Has license ever been encumbered (denied, revoked, suspended, surrendered, limited, placed on probation)?
**[ ] YES
[ ] NO
** If yes, please send certified copies of Board actions.
Licensing Board must affix seal and sign document below:
Signature:________________________________________________________________________
(SEAL)
Title:
_________________________________________________________________________
State:
_________________________________ Date:___________________________________
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