Instructions For Clinical Nurse Specialist (CNS) Applicants
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1 RETAIN FOR REFERENCE Instructions For Clinical Nurse Specialist (CNS) Applicants GENERAL INFORMATION: An applicant for Clinical Nurse Specialist certification must hold a current, unrestricted license as a registered nurse in this Commonwealth. An individual who meets the requirements of Section 3(b) of the Professional Nurse Law has the right to use the title Clinical Nurse Specialist and the abbreviation CNS. If you hold or ever held CNS certification in Pennsylvania, your Pennsylvania certification must be reactivated. DO NOT PROCEED with this application. INSTRUCTIONS: FEES: Mail the completed application and fee to the Board at the above address. All questions must be answered completely and all fees submitted in order for the application to be processed. To verify that the CNS certificate was issued visit Social Security Numbers must be provided.* If a Waiver of Social Security Number form is submitted in lieu of a Social Security Number, it cannot be used to renew a CNS certificate. Application must be received in the Board office within 90 days from the date the affidavit is signed. Applications are valid for one year from the date the affidavit is signed. If a CNS certificate is not issued within the one year, a new application, including fees, must be submitted. The $100 fee must be paid by personal check, cashier s check or money order and must be made payable to the Commonwealth of Pennsylvania. Fees are nonrefundable. Check/money orders drawn on foreign banks are only acceptable when US funds is identified on the check/money order. A $20.00 processing fee will be charged for a check/money order returned unpaid. Applications will not be processed until the corrected fee is received. NAME / ADDRESS: Applicant s legal name must be entered on the application. CNS certificates are not forwarded. Complete and submit the Form to Request Change of Name &/or Address located on the Board s website, whenever there is a change of name &/or address. Licensees are responsible to advise the Board of any address or name change within 10 days of the change. QUESTIONS: If YES was checked for any question in Section B, submit: A detailed, signed and dated personal explanation explaining the action, its background and any rehabilitation. A Criminal History Records Check (CHRC) from a State Law Enforcement Authority in all states where you lived in the last five years. All background check documents cannot be older than 90 days from the date of issuance. (Applicable ONLY to #B4 and #B5) Copies of criminal Court documents. (Applicable ONLY to #B4 and #B5) Certified copies of all disciplinary actions from the Boards that imposed action (Applicable ONLY to #B1, #B2 and #B3). CHILD ABUSE CONTINUING EDUCATION REQUIREMENT: EFFECTIVE JANUARY 1, 2015, all persons applying for issuance of an initial license shall be required to complete 3 hours of DHSapproved training in child abuse recognition and reporting requirements as a condition of licensure. Review the Board website for further information on approved CE providers. Once you have completed a course, the approved provider will electronically submit your name, date of attendance, etc., to the Board. Board approved providers may take up to 7 business days to electronically send verification of completion to the Board. A license will not be issued until this electronic verification is received. ACT 31 Mandated Child Abuse Recognition and Reporting Continuing Education Providers * Note that disclosing your Social Security Number on this application is mandatory in order for the State Boards to comply with the requirements of the Federal Social Security Act pertaining to Child Support Enforcement, as implemented in the Commonwealth of Pennsylvania at 23 Pa.C.S (a). At the request of the Department of Human Services (DHS), the licensing boards must provide to DHS information prescribed by DHS about the licensee, including the social security number. In addition, Social Security Numbers are required in order for the Board to comply with the reporting requirements of the U.S. Department of Health and Human Services, National Practitioner Data Bank. 1
2 LICENSURE REQUIREMENTS An applicant for CNS certification must meet the following requirements: 1. Hold a graduate degree from a Board-approved or equivalent CNS program OR an educational program in a related discipline previously recognized for national certification as a CNS by the American Nurses Association or the American Nurses Credentialing Center. 2. Hold current national certification or its equivalence National certification requires the passing of a national certifying examination in the specialty in which the applicant is seeking certification by the Board. Recognized national certification organizations include: o American Nurses Credentialing Center (ANCC) o American Association of Critical Care Nurses (AACN) o Orthopedic Nurses Certification Board (ONCB) o Oncology Nursing Certification Corporation (ONCC) An applicant who is not eligible for national certification, must demonstrate BOTH that: o The applicant s educational program does not make the applicant eligible to take a national certification examination. o The applicant has experience in the CNS role through education and work history. APPLICATION SUBMISSION REQUIREMENTS 1. Submit a completed Application for Certification as a CNS found at the Board s website and the $100 fee to the Board. If you do not have a Social Security Number, complete the Waiver of Social Security Number form. State the reason why you do not have a Social Security Number. An official transcript must be mailed directly to the Board (ATTN: CRNP AREA) from the CNS education program that awarded the degree, certificate. o The CNS education program is the institution, school, college, or university where you completed the CNS education that qualified you for your original CNS license. o A Non-official transcript, such as a student copy, or a student-submitted copy that was provided to the student by the program in a sealed official envelope, is not acceptable. o The official transcript must designate the degree awarded with the month, day, and year the program was completed. 2. Have submitted a completed Verification of Clinical Nurse Specialist Education. o Forward the Verification of Clinical Nurse Specialist Education Program form to your CNS education program for completion. o The verification must be mailed directly to the Board from your CNS education program. 3. Have submitted a completed Verification of National Certification or its equivalence. o If you hold national certification: Have your national certification organization send a verification of your certification directly to the Board. Copies receivedfrom applicants are not acceptable. o If you are not eligible for national certification, forward the following to the Board: Course descriptions fromyour CNS education program. Current curriculum vitae. Work history in the CNS role. Three professional recommendations from individuals knowledgeable about the applicant s work experience in the CNS role. Any additional advanced nursing education official transcripts. Current national nursing certification(s). 4. If licensed as a CNS in another state or jurisdiction, have submitted a completed Verification of Licensure. o Complete Section A of the Verification of Licensure form and forward it to the jurisdiction where you hold a CNS license for completion. o The verification must be mailed directly to the Board from that jurisdiction. o Contact that jurisdiction directly about any fee charged for completion of the Verification. SPECIALTY DESIGNATION The specialty designation listed on the Pennsylvania CNS certificate will match the national certification designation. A CNS who is not eligible for national certification will receive the designation without specialty on the Pennsylvania CNS certificate. MALPRACTICE INSURANCE REQUIREMENT Once licensed, a CNS must maintain professional liability coverage at a level required for non participating health care providers. 2
3 APPLICATION FOR CERTIFICATION AS A CLINICAL NURSE SPECIALIST (CNS) Attach the $100 fee and required documents. All fees are non-refundable. SECTION A: APPLICANT INFORMATION: Print clearly in Blue or Black Ink Only. Pennsylvania RN License Number: _ Expiration Date: _ Last First Middle Maiden Please list any other name(s) appearing on official documents Date of Birth: Address: U.S. Social Security Number: Month Day Year Street City State Zip ( ) Address: Daytime Phone Number SECTION B: QUESTIONS: ANSWER THE FOLLOWING QUESTIONS: 1. Have you had disciplinary action taken against a professional or occupational license, certificate, permit, registration or other authorization to practice a profession or occupation issued to you in any state or jurisdiction or have you agreed to voluntary surrender in lieu of discipline? 2. Do you currently have any disciplinary charges pending against your professional or occupational license, certificate, permit or registration in any state or jurisdiction? YES NO Have you withdrawn an application for a professional or occupational license, certificate, permit or registration, had an application denied or refused, or for disciplinary reasons agreed not to apply or reapply for a professional or occupational license, certificate, permit or registration in any state or jurisdiction? Have you been convicted (found guilty, pled guilty or pled nolo contendere), received probation without verdict or accelerated rehabilitative disposition (ARD), as to any criminal charges, felony or misdemeanor, including any drug law violations? Note: You are not required to disclose any ARD or other criminal matter that has been expunged by order of a court. 3
4 SSN: Do you currently have any criminal charges pending and unresolved in any state or jurisdiction? Do you currently engage in, or have you ever engaged in, the intemperate or habitual use or abuse of alcohol or narcotics, hallucinogenics or other drugs or substances that may impair judgment or coordination? Have you ever had your DEA registration denied, revoked or restricted? YES NO Have you ever had provider privileges denied, revoked, suspended or restricted by a Medical Assistance agency, Medicare, third party payor or another authority? Have you ever had practice privileges denied, revoked, suspended or restricted by a hospital or any health care facility? Have you ever been charged by a hospital, university, or research facility with violating research protocols, falsifying research, or engaging in other research misconduct? SECTION C: PROFESSIONAL INFORMATION: 1. Are you recognized as a Clinical Nurse Specialist (active or inactive status) by any other state? YES NO 2. Do you hold, or have you ever held, a license, certificate, permit, registration or other authorization to practice a profession or occupation in any state or jurisdiction? If you answered yes to the above question, please provide the profession and state or jurisdiction. Please do not abbreviate the profession. STATE / COUNTRY PROFESSION If necessary, please attach a page with additional licensure information. 4
5 SSN: SECTION D: CLINICAL NURSE SPECIALIST EDUCATION: Type of Graduate Degree Awarded: Master s Post-Master s Doctorate Other (Select One) (Specify) Full Name of the CNS Education program: (No abbreviations) City State Program Specialty: Program Completion Date: SECTION E: CNS NATIONAL CERTIFICATION: (If you do not hold current national CNS certification also complete Section F) Were you eligible to take a CNS national certification exam upon program completion? Yes I hold Current National certification from as a CNS in. (National Certification Organization) (Specialty) Expiration date: _. No SECTION F: NATIONAL CERTIFICATION EQUIVALENCE AT T E ST AT I O N (Complete this section only if you do not hold current national certification) This is to certify that I am not eligible to take any national CNS certification exam(s). I am not eligible for national certification as a clinical nurse specialist because: (state reason) SECTION G: AFFIDAVIT: READ, SIGN AND DATE. ALL APPLICANTS MUST COMPLETE THIS SECTION. I verify that this application is in the original format as supplied by the Department of State and has not been altered or otherwise modified in any way. I am aware of the criminal penalties for tampering with public records or information under 18 Pa.C.S I verify that the statements in this application are true and correct to the best of my knowledge, information and belief. I understand that false statements are made subject to the penalties of 18 Pa.C.S (relating to unsworn falsification to authorities) and may result in the suspension, revocation or denial of my license, certificate, permit or registration. Applicant s Full Legal Signature Date VALID FOR ONE YEAR 5
6 VERIFICATION of CLINICAL NURSE SPECIALIST EDUCATION PROGRAM This form is to be completed in its entirety by the present Program Director or designee of the CNS Education Program AFTER ALL PROGRAM REQUIREMENTS HAVE BEEN MET. Name of Graduate: Provide the last 4 numbers of the graduate s Social Security Number: XXX-XX- Full Name of the College or University (no abbreviations): Date of Birth: (MM/DD/YY) Mailing Address: (City) (State) (Zip Code) Type of Program: CNS_ Other Program Specialty: Date graduate completed the program: _ Graduate Degree Awarded: _ (MM/DD/YY) MSN, DNP, POST-MASTER S, OTHER Did completion of this program make graduates eligible to take a CNS national certification exam? Yes No If yes: National Certification Organization: Specialty Total number of clinical experience hours completed by this graduate: Length of program: Program Accreditation: CCNE ACEN (Months) I certify that all of the above information is correct. I understand that any false statement made is subject to the penalties of 18 Pa. C.S relating to unsworn falsification to authorities and may result in sanctions of my license or certificate and/or disposition of civil penalties. I verify that this form is in the original format as supplied by the Department of State and has not been altered or otherwise modified in any way. I am aware of the criminal penalties for tampering with public records or information pursuant to 18 Pa. C.S X Original Signature of Program Director/designee (Name stamp is not acceptable) [SCHOOL SEAL] Print or type the name of Program Director/designee Program Director/designee s Contact Phone Number Date Signed DO NOT RETURN THIS FORM TO APPLICANT. MAIL IT IN AN OFFICIAL SCHOOL ENVELOPE TO: CNS Applications 2601 North Third Street P.O. Box 2649 Harrisburg, PA Harrisburg, PA (717)
7 Section A. Completed by Applicant only. VERIFICATION OF CLINICAL NURSE SPECIALIST LICENSURE Date of Birth: Last First Middle Maiden Name MM DD YYYY Current Address: Street City State Zip Code Social Security Number: - - Current Licensure / Certification: State License Number Section B. Completed by Original Licensing Authority only. This is to certify that Applicant s Name was issued license/certification number Specialty: (If Applicable) as a CNS in the following Date Issued: Expiration Date Current licensure/certification Status: O Active O Inactive O Lapsed Basis for Licensure: O Endorsement O National Certification O Waiver O Other: Has this license ever been disciplined in any manner or are disciplinary charges pending? Check one: O No O Yes (If yes, please send certified copies of Board actions) CNS/Advanced Nursing Education Program: Location: (City, State/Province/Territory): Program Completion Date: Approved by State/Province/Territory: O Yes O No Specialty: (If Applicable) (SEAL) Original Signature of Licensing Officer: Title: Name of Licensing Authority: Address: Date: DO NOT RETURN THIS FORM TO APPLICANT. CNS Applications 2601 North Third Street P.O. Box 2649 Harrisburg, PA Harrisburg, PA (717)
PENNSYLVANIA STATE BOARD OF NURSING PHONE (717) 783-7142 P.O. BOX 2649 FAX (717) 783-0822
PENNSYLVANIA STATE BOARD OF NURSING PHONE (717) 783-7142 P.O. BOX 2649 FAX (717) 783-0822 HARRISBURG, PA 17105-2649 www.dos.state.pa.us/nurse Email: st-nurse@state.pa.us RETAIN FOR REFERENCE General Instructions
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PENNSYLVANIA STATE BOARD OF NURSING PHONE: (717) 783-7142 P.O. BOX 2649 FAX: (717) 783-0822 HARRISBURG, PA 17105-2649 www.dos.state.pa.us/nurse Email: st-nurse@pa.gov RETAIN FOR REFERENCE General Instructions
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This is a Legal Document. By completing and signing, this you certify under
APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) BY ENDORSEMENT, or DEEMING *All certificates expire December 31 of every EVEN year* This is a Legal Document. By completing and signing, this
Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE. LICENSE BY ENDORSEMENT Applicant must submit the following:
Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing (802) 828-2396 www.vtprofessionals.org Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED
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New Mexico Regulation and Licensing Department BOARDS AND COMMISSIONS DIVISION Counseling and Therapy Practice Board PO Box 25101 Santa Fe, New Mexico 87505 (505) 476-4610 Fax (505) 476-4645 www.rld.state.nm.us
LICENSURE BY EXAMINATION APPLICATION
LICENSURE BY EXAMINATION APPLICATION SEND APPLICATION TO: PSI/Colorado Barber Cosmetology Program PO Box 887 Wheat Ridge, CO 80034 EXAMINATION Please select practical skills examination(s) that you are
Clinical Nurse Specialist General Instructions for Licensure Application
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Instructions and Information APPLICATION FOR ADVANCED PRACTICE REGISTERED NURSE AUTHORIZATION
The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health Division of Health Professions Licensure Board of Registration in Nursing www.mass.gov/dph/boards/rn
BOARD OF ATHLETIC TRAINING STATE OF FLORIDA EXAMINATION APPLICATION FOR LICENSURE
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PHARMACIST LICENSE APPLICATION
THE STATE Department Commerce, Community, and Economic Development In accordance with AS 08.80.410, a person may not assume or use the title "pharmacist," or any variation the title, or hold out to be
Vermont Board of Nursing INSTRUCTION TO APPLICANTS
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CERTIFYING ORGANIZATION CERTIFICATION TYPE EFFECTIVE DATE EXPIRATION DATE
Fee $105.00 U.S. No personal checks. All fees are nonrefundable. 2829 University Avenue SE #200 Minneapolis, MN 55414-3253 (612) 317-3000 Voice (612) 617-2190 Fax Toll Free (888) 234-2690 (MN, IA, ND,
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE PHYSICAL THERAPIST
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Applying on the Basis of Examination
Vermont Secretary of State, Board of Veterinary Medicine Montpelier, Vermont 05620-3402 PHONE: (802) 828-2373 FAX: (802) 828-2465 E-mail address: Aprille.Morrison@sec.state.vt.us Web site: www.vtprofessionals.org
APPLICATION FOR REGISTERED NURSE BY ENDORSEMENT
THE STATE of ALASKA Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing Board of Nursing 550 West 7 th Avenue, Suite 1500 Anchorage,
DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions
DEPARTMENT OF HEALTH BOARD OF CLINICAL SOCIAL WORK, MARRIAGE AND FAMILY THERAPY AND MENTAL HEALTH COUNSELING APPLICATION FOR LIMITED LICENSURE and Instructions APPLICATION FOR LIMITED LICENSURE INSTRUCTIONS
TECHNICIAN-IN-TRAING IS NOT PERMITTED TO PRACTICE IN MONTANA IN ANY MANNER WITHOUT AN ACTIVE MONTANA REGISTRATION
Page 1 of 8 MONTANA BOARD OF PHARMACY (301 S PARK, 4 TH FLOOR, HELENA, MT 59601 - Delivery) P. O. Box 200513 Helena, Montana 59620-0513 PHONE (406) 841-2300 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov
Application for Approval to Sit for the Pennsylvania State Specific Land Surveying (PLS) Examination
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This is a Legal Document. By completing and signing this, you certify under
APPLICATION FOR WYOMING REGISTERED NURSE (RN) or LICENSED PRACTICAL NURSE (LPN) By EXAMINATION *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this,
VOCATIONAL REHABILITATION COUNSELOR
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE VOCATIONAL REHABILITATION COUNSELOR APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah Division
State of Utah Department of Commerce Division of Occupational and Professional Licensing
State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Veterinarian APPLICANT INFORMATION Full Legal Name: First Middle Last All Previous Legal Names:
REQUIREMENTS FOR LICENSURE BY EXAMINATION
2829 University Avenue SE #200 Minneapolis, MN 55414-3253 (612) 317-3000 Voice (612) 617-2190 Fax Toll Free (888) 234-2690 (MN, IA, ND, SD, WI) (800) 627-3529 TTY Email: nursing.board@state.mn.us Website:
State of Utah Department of Commerce Division of Occupational and Professional Licensing
State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Retired Volunteer Health Care Practitioner APPLICANT
Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing
MED THE STATE of ALASKA Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing State Medical Board PO Box 110806, Juneau, AK 99811-0806
WYOMING LICENSED PRACTICAL NURSE LICENSURE BY ENDORSEMENT, RELICENSURE
APPLICATION FOR WYOMING LICENSED PRACTICAL NURSE LICENSURE BY ENDORSEMENT, RELICENSURE or REACTIVATION All licenses expire December 31 of every EVEN year INSTRUCTIONS AND GENERAL INFORMATION: Thank you
APPLICATION FOR NATIONAL EXAMINATION IN MARITAL & FAMILY THERAPY
Minnesota Board of Marriage and Family Therapy 2829 University Avenue SE, Suite 400 Minneapolis, MN 55414-3222 Telephone: (612) 617-2220 Fax: (612) 617-2221 Email: mft.board@state.mn.us Website: www.bmft.state.mn.us
REHAB PROVIDER NETWORK Professional Staff Credentialing Form
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APPLICATION FOR LICENSURE LICENSED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR INTERN
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ADVANCED PRACTICE REGISTERED NURSE (APRN) or APRN-CRNA WITHOUT PRESCRIPTIVE PRACTICE
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APPLICATION FOR PRIVATE ACADEMIC SCHOOL TEACHING CERTIFICATE FORM PDE 4536 (Refer to instructions included with this two page form)
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APPLICATION FOR REINSTATEMENT OF NURSE AIDE CERTIFICATION
THE STATE of ALASKA Department of Commerce, Community, and Economic Development Nurse Aide Registry 550 West 7 th Avenue, Suite 1500 Anchorage, AK 99501 Phone: (907) 269-8169 Fax: (907) 269-8196 Email:
APPLICATION FOR ATHLETIC TRAINER LICENSURE INSTRUCTION TO APPLICANTS
Judith Griffen, Administrative Assistant ATHLETIC TRAINER APPLICATION FOR ATHLETIC TRAINER LICENSURE INSTRUCTION TO APPLICANTS A. LICENSE BY EXPERIENCE: Applicants must submit the following: 1. Complete
Board of Speech-Language Pathology and Audiology
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Dear Applicant: Sincerely, Kelli Dalrymple, Coordinator Medical and Specialized Health. Licensure Unit
Please Reply To: Licensure Unit P.O. Box 94986, Lincoln, NE 68509-4986 Phone (402) 471-2118 FAX (402) 471-3577 Dear Applicant: Thank you for your interest in becoming licensed to practice your profession
STATE OF FLORIDA BOARD OF MASSAGE THERAPY MASSAGE ESTABLISHMENT CHANGE OF LOCATION/ NAME APPLICATION WITH INSTRUCTIONS
STATE OF FLORIDA BOARD OF MASSAGE THERAPY MASSAGE ESTABLISHMENT CHANGE OF LOCATION/ NAME APPLICATION WITH INSTRUCTIONS Board of Massage Therapy 4052 Bald Cypress Way, #C-06 Tallahassee, FL 32399-3256 (850)
INSTRUCTION SHEET PHARMACY TECHNICIAN
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Application for Veterinary Technician Licensure in Nebraska
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PLEASE READ BEFORE COMPLETING APPLICATION
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EFFECTIVE NEBRASKA HEALTH AND HUMAN SERVICES 172 NAC 100 7/21/04 REGULATION AND LICENSURE PROFESSIONAL AND OCCUPATIONAL LICENSURE TABLE OF CONTENTS
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State of Florida Department of Business and Professional Regulation Mold Related Services Application for Licensure Form # DBPR MRS 0701
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APPLICATION FOR WYOMING REGISTERED NURSE LICENSURE by ENDORSEMENT, RELICENSURE or REACTIVATION All licenses expire December 31 of every EVEN year
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Massachusetts Board of Registration in Pharmacy. Pharmacy Technician Registration Application
The Massachusetts Board of (Board) has contracted with Professional Credential Services (PCS) to process registration applications from pharmacy technicians. Applicants must submit all information directly
Application Letter of Instruction
STATE OF NEVADA BOARD OF OCCUPATIONAL THERAPY P.O. BOX 34779 Reno, Nevada 89533-4779 (775) 746-4101 / Fax: (775) 746-4105 / Toll Free: (800) 431-2659 Email: board@nvot.org / Website: www.nvot.org TYPES
STATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR COLON HYDROTHERAPY UPGRADE TO MASSAGE THERAPIST LICENSE WITH INSTRUCTIONS
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State of Utah Department of Commerce Division of Occupational and Professional Licensing
State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Temporary Physical Therapist Temporary Physical Therapist Assistant APPLICANT INFORMATION Full Legal