Fillable ONLINE NURSE PRACTITIONER APPLICANT IDENTIFICATION FORM Board of (California)

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ONLINE NURSE PRACTITIONER APPLICANT IDENTIFICATION FORM Board of (California)

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Country of origin: US
File type: PDF

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BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov
ONLINE NURSE PRACTITIONER APPLICANT IDENTIFICATION FORM
You must complete and submit this form via your online BreEZe account, or by mailing to:
Board of Registered Nursing, ATTN: Advanced Practice Unit, P.O. Box 944210, Sacramento, CA 94244-2100.
Print Full Name:
(Last)
(First)
(Middle)
U.S. Social Security
Number or Individual
Tax Identification
Number:
E-Mail:
Address:
Date of
Birth:
City, State and Country of Nurse Practitioner
Program:
HAVE YOU COMPLETED AND/OR ENCLOSED THE FOLLOWING ITEMS (check all that apply):
Have you attached a recent 2” x 2” passport type photograph?
YES
NO
If applicable, is supplemental information regarding reporting prior convictions or discipline
against licenses enclosed?
YES
NO
Tape Your 2” x 2”
Passport Type
Photograph Here
I certify under penalty of perjury under the laws of the State of California,
that all information provided in connection with this online application for
licensure is true, correct and complete. Providing false information or
omitting required information is grounds for denial of licensure or license
revocation in California.
Signature of Applicant:
Date:
(Rev. 1/19)
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ONLINE NURSE PRACTITIONER APPLICANT IDENTIFICATION FORM Board of (California)

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Completed 21 May 2021

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