Doug Ducey Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
1740 W Adams Street, Suite 2000
Phoenix, AZ 85007
Phone (602) 771-7800
Website: www.azbn.gov
AFFIDAVIT RE: SOCIAL SECURITY NUMBER
1. Th
is form must be completed by professional nurse, practical nurse and certified nursing assistant applicants who state they do not
have a social security number.
2. A.R.S. § 25-320(K) requires that:
Each licensing board or agency that issues professional, recreational or occupational licenses or certificates shall record on the
application the social security number of the applicant and shall enter this information in its data base in order to aid the
department of economic security in locating parents or their assets or to enforce child support orders.
3. I certify that I do not have a social security number because
4. I understand that in the event I obtain a social security number, I have the obligation to provide the Board with a copy of my social
security card within 10 days. My failure to do so may result in disciplinary action against my license/certificate.
5. I understand that I must provide the Board, in writing with the name and address of my initial Arizona nursing employer, within 10
days of commencing employment.
AFFIDAVIT
The undersigned being duly sworn declares that he/she has read and understands this affidavit; understands that failure to disclose the
requested information or disclosure of false or misleading information may constitute fraud and may result in denial of
licensure/certification or disciplinary action, up to and including revocation, taken against an issued license or certificate. Failure to
disclose the requested information or disclosure of false or misleading information may also result in criminal prosecution.
__________________________________________
Type or Print Your Name
JURAT
State of_________________________ ) __________________________________________
) SS Signature
County of _______________________ )
______________________________________ personally appeared before me, and under oath, swears that the statements made
NAME
in this document and all attachments are true and correct this _______________day of ___________________, 20_______
___________________________________________________ ____________________________
NOTARY PUBLIC MY COMMISSION EXPIRES
