This document is an application for licensure by examination from the Northern Mariana Islands Board of Nursing. It contains instructions for applicants, including submitting the appropriate fee and attaching recent photos. The application requests personal information such as name, address, education and licensing history. Applicants must disclose any previous disciplinary actions or criminal convictions. They must also sign an affidavit verifying the truthfulness of their application statements.
This document is an application for licensure by examination from the Northern Mariana Islands Board of Nursing. It contains instructions for applicants, including submitting the appropriate fee and attaching recent photos. The application requests personal information such as name, address, education and licensing history. Applicants must disclose any previous disciplinary actions or criminal convictions. They must also sign an affidavit verifying the truthfulness of their application statements.
This document is an application for licensure by examination from the Northern Mariana Islands Board of Nursing. It contains instructions for applicants, including submitting the appropriate fee and attaching recent photos. The application requests personal information such as name, address, education and licensing history. Applicants must disclose any previous disciplinary actions or criminal convictions. They must also sign an affidavit verifying the truthfulness of their application statements.
This document is an application for licensure by examination from the Northern Mariana Islands Board of Nursing. It contains instructions for applicants, including submitting the appropriate fee and attaching recent photos. The application requests personal information such as name, address, education and licensing history. Applicants must disclose any previous disciplinary actions or criminal convictions. They must also sign an affidavit verifying the truthfulness of their application statements.
READ ALL DETAILED INSTRUCTIONS For Official Use Only
1. Submit the APPROPRIATE FEE. Payments must be made Nursing School transcript ………Approved……. .By…………. payable to “NMI BON or NMI Board of Nursing” Birth Certificate………………. Approved…… By…………. in US postal money order or cashier’s check from US Bank. Marriage Certificate…………… Approved…… By…………. Copy of RN License Rec’d……. Approved…… By…………. 2. Attach two (2) 2”x2” photos taken within the last six (6) Fee Received………...Receipt #……………….. By…………. months and signed on the bottom front portion of the photo.
REGISTERED NURSE LICENSED PRACTICAL NURSE
Print or Type 1. LAST NAME: FIRST NAME: MIDDLE NAME:
2. ADDRESS: 3. DATE OF BIRTH:
4. CITY STATE COUNTRY ZIP CODE 5. SOCIAL SECURITY NUMBER:
9. MOTHER’S MAIDEN NAME: 10. COLOR OF EYES: 11. HEIGHT:
12. PRIMARY LANGUAGE: 13. HIGH SCHOOL ATTENDED AND YEAR OF GRADUATION:
14. PROFESSIONAL EDUCATION: (Name and address of nursing school completed)
15. Entrance Date: 16. Completion Date: 17. Type of Program:
AD DI BSN Advanced 18. Have you ever been known by any other name than that listed above? Yes No If answer is yes, please list name(s) here and explain.
19. Have you ever had disciplinary proceedings against any license as a RN or LPN or any health-care related license including revocation, suspension, probation, voluntary surrender, or any other proceeding in any state, territory or country? If yes, please provide a detailed written explanation, including the date and state or country where the discipline occurred.
20. Have you ever been convicted of any offense other than minor traffic violation? If yes, please explain fully.
21. Have you ever sat for the NCLEX-RN/LPN Exam or the SBTPE? Yes No Passed Failed YEAR: _______________
Place 2”x2” photo here.
Signature In Full: ____________________________________________ Date: ______________________________________ CBNE – Doc 22
AFFIDAVIT
I, the undersigned, being duly sworn, say that I am the person referred to in the foregoing application for registration as a nurse in the Commonwealth of the Northern Mariana Islands, that the statements therein are true to the best of my knowledge and belief.
I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind, and I declare under penalty of perjury that my answers and all statements made by me herein are true and correct. Should I furnish any false information in this application, I hereby agree that such act(s) shall constitute cause for the denial, suspension, or revocation of my license to practice as an advanced practitioner in the Commonwealth of the Northern Mariana Islands.
------------------------------------- Signature of Applicant
Subscribed and sworn to before me
this _________ day of ________________,
20__________.
___________________________________ (SEAL) Signature of Notary Public
Thời gian làm bài: 60 phút không kể thời gian phát đề Họ tên học sinh: Đào Minh Ngọc (11h4' - 11h 34') Số báo danh: .....................................................................
