License Verification Request - Florida Board Of Nursing
ADVERTISEMENT
1Complete verifications must be mailed, or sent electronically, directly from the verifying agency to:
Florida Board of Nursing
4052 Bald Cypress Way
Bin # C02
Tallahassee, FL 32399-3252
Florida Board of Nursing
License Verification Request
Who needs to use this form?
•
Applicants whose state(s) do not participate in the Nursys system should use this form.
All applicants are required to provide verification of their initial license and an active license.
*
*
A large number of states verify licensure using the Nursys system. Applicants should check
and see if their state participates in the Nursys system by logging on to
*
Verification must be sent directly to our office by the verifying agency. Copies of licenses and
website screen shots do not meet the requirement for verification of licensure.
*
You are responsible for fees incurred for verification of your licensure.
PART I: TO BE COMPLETED BY APPLICANT (Send to your original and current state(s) of
licensure. No verification is required for previous Florida licenses. Make copies as necessary.)
SSN:_____________________
Applicant Name: ____________________________________________
Address:_____________________________________________________________________________
Name original license was issued under:
License Number:
State of:
I hereby authorize release of any information regarding my licensure status to the Florida Board of Nursing.
Applicant Signature: ____________________________________________ Date: __________________
***************************************************************************************************************************************
PART II: TO BE COMPLETED BY YOUR STATE BOARD OF NURSING
All verifications must be in English and include the following criteria:
* Typed on an official state form or letterhead
* Include an official Board seal
* Signature and title of state Board official
The following information must be included in all verifications:
* License number
* State or jurisdiction of licensure
* Licensee name
* Licensure status
* Is license in good standing?
* Level of licensure (RN/LPN)
* Dates of issuance/expiration
* Licensure method (state exam, national exam, endorsement, reciprocity)
* Has this license ever been encumbered (denied, revoked, suspended surrendered, limited, placed on
probation)?
* If this license has ever been encumbered please forward all orders to the Florida Board of Nursing with this
form.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal