Fillable PUBLIC HEALTH NURSE APPLICANT IDENTIFICATION FORM Board of (California)

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PUBLIC HEALTH NURSE APPLICANT IDENTIFICATION FORM Board of (California)

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The PUBLIC HEALTH NURSE APPLICANT IDENTIFICATION FORM Board of (California) form is 1 page long and contains:

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Country of origin: US
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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
PUBLIC HEALTH NURSE 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 No:
E-Mail:
Address:
Name of Public Health Nurse Program:
City, State and Country of Public Health Nurse
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, have you attached a copy of the Child Abuse completion certificate?
YES
NO
If applicable, are you relocating to California as a result of your spouse’s/partner’s active duty
military service, is the supplemental information enclosed?
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
license/certification is true, correct and complete. Providing false
information or omitting required information is grounds for denial of
licensure/certification or license/certificate revocation in California. I have
read and understand the disclosure statements provided in the
instructions for this application. I hereby grant the Department of
Consumer Affairs entity permission to verify any information contained in
this application.
Signature of Applicant:
Date:
(Rev. 1/19)
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PUBLIC HEALTH NURSE APPLICANT IDENTIFICATION FORM Board of (California)

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Completed 4 August 2021

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