Forms

Consumers

Document Title
Customer Service Evaluation Form

Applicants

Document Title
Application for California Public Health Nurse Certificate
Application for Clinical Nurse Specialist (CNS) Certification
Application for Licensure by Examination
Application for Licensure by Examination (8-Year Retake)
Application for Licensure by Endorsement
Application for Nurse Anesthetist (NA) Certification
Application for Nurse-Midwife (NM) Certification
Application for Nurse Practitioner (NP) Certification
Application for the Listing as a Psychiatric/Mental Health (P/MH) Nurse
Change of Address
Notification of Name Change
Notification of Social Security Number Change
Nurse Midwife Furnishing Number Application
Nurse Practitioner Furnishing Number Application
Online Clinical Nurse Specialist Applicant Identification Form
Online Examination Applicant Identification Form
Online Licensure by Endorsement Applicant Identification Form
Online Nurse Anesthetist Applicant Identification Form
Online Nurse-Midwife Applicant Identification Form
Online Nurse-Midwife Furnishing Number Application Identification Form
Online Nurse Practitioner Applicant Identification Form
Online Nurse Practitioner Furnishing Number Application Identification Form
Online Public Health Nurse Applicant Identification Form
Online RN Request for Repeat/Reapply Examination Identification Form
Request for Accommodation of Disabilities
Request for Authorization to Practice Without a California License at a Sponsored Free Health Care Event
Fingerprint Request for Live Scan
Request for Reapply/Repeat Examination
Request for Transcript

Education

Document Title
Continuing Approval - Nursing Program
New School of Nursing - Feasibility Study Report
Request for Major Curriculum Revision

Licensees

Document Title
Active to Inactive License
Application for Reinstatement of a Lapsed License - 8-Year Renewal
Change of Address
Continuing Education Provider Initial Renewal Notice
Fingerprint Request for Live Scan
Inactive to Active License
Notification of Name Change
Notification of Social Security Number Change
Renewal Fingerprint Question Certification
Request for Duplicate Certificate

Enforcement

Document Title
Complaint
Expert Practice Consultant Application
Report of Settlement, Judgment, or Arbitration Award

Probation

Document Title
BRNPROB100 - AA-NSG Calendar BRNPROB112 - Mental Examination Form
BRNPROB101 - RN WPE BRNPROB113 - Employment Approval Form
BRNPROB102 - NP WPE BRNPROB114 - Fingerprint Instructions and Form
BRNPROB103 - CRNA WPE BRNPROB115 - First Source Enrollment Instructions
BRNPROB104 - CNM WPE BRNPROB116 - Rehabilitation - Treatment Form
BRNPROB105 - Tolled Update Form BRNPROB117 - Cost Recovery - Payment Plan
BRNPROB106 - Tolled - Request to Go into Tolled Status BRNPROB118 - Data Form
BRNPROB107 - Confidential Release Form BRNPROB119 - EDD Authorization for Release
BRNPROB108 - Physical Examination Form BRNPROB120 - Refresher Course and Clinical Approval Form
BRNPROB109 - Therapy Form BRNPROB121 - Early Termination and Modification Application
BRNPROB110 - NSG Facilitator Form BRNPROB122 - Relapse Prevention Plan
BRNPROB111 - Psychotropic Mood Altering Form BRNPROB123 - Rule Out Examination Addendum

Intervention

Document Title
Application for Nurse Support Group Facilitator/Co-Facilitator
Intervention Evaluation Committee (IEC) Application