Idaho Board Of Nursing Affidavit For Change Of Name

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IDAHO BOARD OF NURSING
License No:_________
AFFIDAVIT FOR CHANGE OF NAME
Please complete, have notarized, and return to this office as soon as possible, so that a change of name can be made
on your licensure records. We cannot change the records without legal notarized evidence.
STATE OF
}
}
COUNTY OF
}
I,
being duly sworn, testify that on the:
Present name (print or type)
day of
,
, my name was changed
Month
Year
for the reason checked below:
Marriage to
Divorce from
Other reason (Please explain)
and that prior to this change my name was
and that I am the person who: (check one)
is licensed as a nurse in Idaho - License Number:
RN
LPN
APPN
has made application for licensure as a:
( ) Professional Nurse [R.N.]
( ) Licensed Practical Nurse [LPN}
( ) Advanced Practice Professional Nurse
Certified Nurse-Midwife
Clinical Nurse Specialist
Nurse Practitioner
Registered Nurse Anesthetist
Signature
Address
City, State, Zip
On this
day of
, in the year of
, before me
, a notary public, personally appeared
, known or identified to me, to be the
person whose name is subscribed to the within instrument, and acknowledged to me that he/she executed
the same.
WITNESS my hand and official seal.
Notary Public
My Commission expires
PO Box 83720, Boise, Idaho 83720-0061
11/00
LTR________

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