Licensure Verification

Red text and boxes with yellow shading are REQUIRED fields.

Personal Information:
First Name:        Middle Initial:
Last Name:       
Your Title:       
Social Security #:       
License State:       
License #:       
Exp. Date:       
(Official use only)

Nursing Board:
The nurse whose name appears above has applied for a position as a traveling nurse with our company. Please provide a written confirmation regarding the standing of the nurse's license.

Has any past or current disciplinary action been taken or is any action pending against this nurse?
Yes   No

Professional Nursing Service is hereby given permission to obtain written verification regarding the standing of my professional licensure including any past, current or pending disciplinary action.
  Yes      Date: