LARA/BPL-NCLEXSCORE (Rev. 11/2018)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital
status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to
this agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-0199
www.michigan.gov/bpl
bpldata@michigan.gov
NCLEX SCORE TRANSFER REQUEST
Authority: 1978 PA 368
TH
IS FORM IS ONLY REQUIRED FOR APPLICANTS WHO HAVE PASSED THE NCLEX BUT HAVE NOT HELD A LICENSE IN ANOTHER STATE.
This form MUST be submitted to both the state that granted NCLEX eligibility and the state of Michigan. Please e-mail a signed copy of
this form to bpldata@michigan.gov
.
Print or Type
Applicant’s Name (First, Middle, Last)
City
State
Zip Code
State NCLEX Eligibility was Granted
NCLEX Candidate ID Number
REQUEST AND SIGNATURE
I am requesting that my NCLEX Examination Pass Notice Results be transferred to the state of Michigan for the purposes
of applying for licensure by examination.
_____________________________________________ _________________________________
Signature Date
