New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
www.NJConsumerAffairs.gov/medical/nursing.htm
Duplicate License Form
Please complete this afdavit, have it notarized and return it to this ofce, together with the appropriate
fee ($35.00 for RNs/LPNs/APNs and $10.00 for CHHAs). (Please submit a certied check or money
order, payable to the Board of Nursing, in the amount of $35.00 for RNs/LPNs/APNs or $10.00 for
CHHAs. No personal checks will be accepted.)
This is to verify that my license/certication to practice as a nurse/CHHA for the current renewal cycle has never
been voluntarily surrendered, revoked or suspended by the New Jersey Board of Nursing, but has been:
Please check one: Lost Destroyed Misplaced Stolen Never Received.
Please check license type: Registered Nurse Licensed Practical Nurse
Advanced Practical Nurse Certied Homemaker-Home Health Aide
I hereby request that a license/certication be issued for the current renewal cycle.
Name:
_____________________________________________________________________________________
License number: _____________________________________________________________________________
Address of record: ___________________________________________________________________________
Mailing address: _____________________________________________________________________________
Social Security Number:
______________________________________________________________________
Date of birth: ________________________________________________________________________________
Telephone number (include area code):
_________________________________________________________
E-mail address:
______________________________________________________________________________
I hereby certify that the foregoing statements made by me are true and correct. I am aware that if any of
the foregoing statements made by me are willfully false, I am subject to punishment.
Sworn to before me this ___________
day of ________________ 201_____ _______________________________________
Signature
________________________________
Notary Public
The Board maintains, as part of its responsibilities, a record of your home address, business address and mailing address. You
may choose which of these addresses will be considered your “address of record.” If you do not indicate which address should
be used as your public address of record, your mailing address will be considered your address of record. *A Post Ofce Box
may be used as your address of record, but only if you provide another address which includes a street, city, state and ZIP code.
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