Fillable VERIFICATION FORM OF NURSING ARIZONA STATE BOARD 1740 (Arizona State Board of Nursing)

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VERIFICATION FORM OF NURSING ARIZONA STATE BOARD 1740 (Arizona State Board of Nursing)

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VERIFICATION FORM
This form
is to be used only if you were originally licensed in the following states/territories: California, Michigan and Pennsylvania
ARIZONA STATE BOARD
OF NURSING
1740 W Adams St, Ste 2000, Phoenix, AZ 85007 Ph:(602) 771-7800
Allow 4-12 weeks for verification to be received by AZ
Verification can also be emailed to AZ. Email: verifications@azbn.gov
PART I: APPLICANT: Complete part I and mail this form to the Board of Nursing of the state or territory where you were
originally licensed. *Please note that most boards charge a fee for this service*
NAME:
___________________________________________________________________________________________
LAST FIRST MIDDLE PREVIOUS NAME(S)
ADDRESS:
___________________________________________________________________________________________
STREET CITY STATE ZIP
NAME WHEN ORIGINALLY LICENSED: DATE OF BIRTH: SOCIAL SECURITY NO:
______________________________________________ ____/____/________ ____-____-________
LAST FIRST
GRADUATION DATE: LICENSE NO.: ORIGINAL STATE OF LICENSURE:
____/________ ________________________ _______________________________
MO YEAR
PART II: ORIGINAL LICENSING BOARD: Complete part II and return directly to the Arizona State Board of Nursing.
ORIGINAL NAME OF LICENSEE: _______________________________________________________________
LAST FIRST
LICENSE NO.: DATE OF ISSUANCE: EXPIRATION DATE:
_____________________ ____/____/________ ____/____/________
ISSUED BY: Exam Endorsement Waiver
LICENSE STATUS: Current
Inactive Lapsed
HAS ANY DISCIPLINARY ACTION BEEN TAKEN AGAINST THIS LICENSE? No
Yes
IF YES, DATE: ________________ ACTION: ____________________________________________________
ARE THERE ANY COMPAINTS OR DISCIPLINARY ACTIONS PENDING? No Yes
IS LICENSEE A GRADUATE OF AN APPROVED NURSING SCHOOL? No Yes
NAME OF NURSING PROGRAM: ________________________________________________________________
LOCATION: _________________________________________________ Graduate Date: ____/____/________
CITY STATE
DEGREE OBTAINED: Diploma Associates in Nursing Bachelors in Nursing
TEST TAKEN: State Board Test Pool Examination (SBTPE) National Council Licensure Exam (NCLEX)
NUMBER OF TIMES CANDIDATE WROTE EXAM: ___________________
DATE OF EXAM: ____/____/________
TEST SERIES/FORM NUMBER ______________
IF NCLEX:
Pass
Fail OR Score ___________
IF SBTPE:
Practical Nurse Score:
____________
Registered Nurse Scores:
MEDICAL PSYCHIATRIC OBSTETRICAL SURGICAL NURSING OF CHILDREN
It is hereby certified that the facts are stated from official evidence on file in the office of the undersigned in relation to the
individual named above.
Signature: Date:
Title:
State Board of Nursing:
Board Seal
PLEASE CONTAC
T APPROPRIATE BOARD FOR CURRENT FEES REQUIRED FOR VERIFICATION
ALABAMA
770 Washington Ave
RSA Plaza, Ste 250
Montgomery, AL 36130-3900
(334) 242-4060
ALASKA
550 W 7th Ave Ste 1500
Anchorage AK 99501-3567
(907) 269-8161
AMERICAN SAMOA
Health Services Regulatory Bd.
LBJ Tropical Med Ctr
Pago Pago, AS 96799
(684) 633-1222
ARIZONA
1740 W Adams Street, Suite
2000 Phoenix, AZ 85007
(602) 771-7800
ARKANSAS
University Tower Bldg
1123 S. University, Ste 800
Little Rock, AR 72204-1619
(501) 686-2700
CALIFORNIA
Board of Registered Nursing
P.O.Box 944210
Sacramento, CA 94244-2100
(916) 322-3350, www.rn.ca.gov
Board of Vocational Nursing
& Psychiatric Technicians
2535 Capitol Oaks Dr, Ste 205
Sacramento, CA 95833
(916) 263-7800,
www.bvnpt.ca.gov
COLORADO
1560 Broadway, Ste 1370
Denver, CO 80202
(303) 894-2430
CONNECTICUT
Board of Examiners for Nursing
Dept of Public Health
410 Capitol Ave, MS# 13PHO
PO Box 340308
Hartford, CT 06134-0328 (860)
509-7603
DELAWARE
861 Silver Lake Blvd
Cannon Building, Ste 203
Dover, DE 19904
(302) 744-4500
DIST. OF COLUMBIA
Department of Health
Health Professional Licensing
Administration
District of Columbia Board of
Nursing
899 North Capitol Street, NE
Washington, DC 20002
(877) 672-2174
FLORIDA
4052 Bald Cypress Way, BIN
C02
Tallahassee, FL 32399
(850) 245-4125
GEORGIA
237 Coliseum Dr
Macon, GA 31217-3858
(478) 207-2440
GUAM
Board of Nurse Examiners
#123 Chalan Kareta
Mangilao, GU 96913-6304
(671) 735-7407
HAWAII
PVLD/DCCA
Attn: Board of Nursing
PO Box 3469
Honolulu, HI 96801
(808) 586-3000
IDAHO
280 N 8
th
St, Ste 210
PO Box 83720
Boise, ID 83720
(208) 334-3110
ILLINOIS
James R Thompson Ctr
100 W Randolph, Ste #9-300
Chicago, IL 60601
312-814-2715
INDIANA
Professional Licensing Agcy
402 W Washington St,
Room W072
Indianapolis, IN 46204
(317) 234-2043
IOWA
RiverPoint Business Park
400 SW 8
th
St, Ste B
Des Moines, IA 50309-4685
(515) 281-3255
KANSAS
Landon State Office Bldg
900 SW Jackson, Ste #1051
Topeka, KS 66612
(785) 296-4929
KENTUCKY
312 Whittington Pkwy,
Ste 300
Louisville, KY 40222
(502) 429-3300
LOUISIANA
Board of Practical Nurse
Examiners
3421 N Causeway Blvd,
Suite 505
Metairie, LA 70002
(504) 838-5791
RN Board of Nursing
17373 Perkins Rd
Baton Rouge, LA 70810
(225) 755-7500
MAINE
158 State House Station
Augusta, ME 04333
(207) 287-1133
MARYLAND
4140 Patterson Ave.
Baltimore, MD 21215
(410) 585-1900
MASSACHUSETTS
Bd of Registration of Nrsg
Commonwealth of MA
239 Causeway St, 2
nd
Fl
Bos
ton, MA 02114
617-973-0800
MI
CHIGAN
MI/DCH/Bureau of Hlth
Professions
Ottawa Building, 611 W
Ottawa, P.O. Box 30004
Lansing, MI 48909 (517)
335-9700,
bplhelp@michigan.gov
MINNESOTA
2829 University Ave SE
Suite 200
Minneapolis, MN 55414
(612)
617-2270
MISSISSIPPI
1935 Lakeland Dr Ste B
Jackson, MS 39216-5014
(601) 987-4188
MISSOURI
3605 Missouri Blvd
PO Box 656
Jefferson City, MO 65102-0656
(573) 751-0681
MONTANA
301 S Park, Ste 401
PO Box 200513
Helena, MT 59620-0513
(406) 841-2345
NEBRASKA
301 Centennial Mall S
Lincoln, NE 68509-4986
(402) 471-4376
Advanced Practice
301 Centennial Mall S
PO Box 94986
Lincoln, NE 68509-4986
(402) 471-6443
NEVADA
5011 Meadowood Mall Way, Ste
300
Reno, NV 89502
(775) 687-7700
NEW HAMPSHIRE
21 S Fruit St, Ste 16
Concord, NH 03301-2431
(603) 271-2323
NEW JERSEY
PO Box 45010
124 Halsey St, 6
th
Fl
Newark, NJ 07101
(973) 504-6430
NEW MEXICO
6301 Indian School Rd, NE, Suite
710
Albuquerque, NM 87110
(505) 841-8340
NEW YORK
Education Building
89 Washington Ave
2
nd
Floor West Wing
Albany, NY 12234
(518) 474-3817 ext 280
NORTH CAROLINA
3724 National Dr, Ste 201
Raleigh, NC 27602
(919) 782-3211
NORTH DAKOTA
919 S. 7
th
St., Suite 504
Bismarck, ND 58504
(701) 328-9777
NORTHERN MARIANA
ISLANDS
Commonwealth Board of Nurse
Examiners
PO Box 501458
Saipan, MP 96950
(670) 664-4810
OHIO
17 S High St., Suite
400
Columbus, OH 43215-3413
(614) 466-3947
OKLAHOMA
2915 N. Classen Blvd, Ste 524
Oklahoma City, OK 73106
(405) 962-1800
OREGON
17938 SW Upper Boones Ferry Rd
Portland, OR 97224
(971) 673-0685
PENNSYLVANIA
PO Box 2649
Harrisburg, PA 17105-2649
(717) 783-7142, st-nurse@pa.gov
PUERTO RICO Commonwealth
of Puerto Rico Board of Nurse
Examiners
800 Roberto H Todd Ave
Room 202, Stop 18
Santurce, PR 00908
(787) 725-7506
RHODE ISLAND
Registration & Nrsg Educ
105 Cannon Building
Three Capitol Hill
Providence, RI 02908
(401) 222-5700
SOUTH CAROLINA
PO Box12367
Columbia, SC 29211
(803) 896-4550
SOUTH DAKOTA
4305 S Louise Ave, Ste 201
Sioux Falls, SD 57106-3115
(605) 362-2760
TENNESSEE
227 French Landing, Ste 300
Heritage Pl MetroCenter
Nashville, TN 37243
(615) 532-5166
TEXAS
333 Guadalupe, Ste 3-460
Austin, TX 78701
(512) 305-7400
UTAH
Heber M Wells Bldg, 4 Flr
160 E 300 South
Salt Lake City, UT 84111
(801) 530-6628
VERMONT
Office of Professional Regulation
National Life Bldg N F1.2
Montpelier, VT 05620-3402
(802) 828-2396
VIRGIN ISLANDS
PO Box 304247
Veterans Drive Station
St. Thomas, VI 00803
(340) 776-7131
VIRGINIA
Dept of Health Professions
Perimeter Center
9960 Mayland Dr, Ste 300
Richmond, VA 23233
(804) 367-4515
WASHINGTON
WA State Nrsg Care QA
Commission, Dept of Hlth
HPQA #6
310 Israel Rd SE
Tumwater, WA 98501-7864
(360) 236-4700
WEST VIRGINIA
WV State Bd of Examiners for
LPNs
101 Dee Drive
Charleston, WV 25311
(304) 558-3572
WV State Bd of Examiners for
RNs
101 Dee Drive
Charleston, WV 25311
(304) 558-3596
WISCONSIN
WI Dept of Reg & Lic
PO Box 8935
Madison, WI 53708-8935
(608) 266-2112
WYOMING
1810 Pioneer Ave
Cheyenne, WY 82001
(307) 777-7601
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VERIFICATION FORM OF NURSING ARIZONA STATE BOARD 1740 (Arizona State Board of Nursing)

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Completed 20 July 2020

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