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NU_RN_Renewal - Current Expiration Vermont Board of Nursing...

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Vermont Board of Nursing Printed from Web National Life Building, North FL 2, Montpelier VT 05620-3402 (802) 828-2396 www.vtprofessionals.org Registered Nurse Renewal Application Current Expiration 03/31/2009 Renewal Period Covering 04/01/2009 through 03/31/2011 Renewal Application Fee $ 95.00 RN license # ___________________________________________ First, Middle, Last Name ______________________________________________ Number & Street Apt./Unit or P.O. Box _________________________________________________ City, State, Zip Code/Postal Code Country ___________________________________________________________ For Office Use Only Directions : To renew you must enclose a check in the amount indicated, payable in US funds from a bank with a United States affiliate to “Office of the Secretary of State”. The renewal application fee is non-refundable. If the renewal application is postmarked after the current expiration date you will be required to pay a late renewal penalty. The penalty is $25.00 for renewals submitted less than 30 days late. Thereafter, the penalty increases by $5.00 for every additional month or fraction of a month, not to exceed $100.00. If you have had a name change please attach a copy of the marriage license, civil union license or section of divorce degree granting you the authority to change your name. To avoid lines and delays, submit your renewal through postal mail. Reminder: You may not work without an active license. PLEASE PRINT CLEARLY. Section A: If mailing address has changed, indicate new address below: ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Note: It is unprofessional conduct for a licensee to fail to notify the Secretary of State’s Office of a change of name or address within thirty (30) days (3 V.S.A. § 129a(a)(14). If your 911 address is different from your mailing address, please indicate the 911 address here: ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Date of Birth ( mm/dd/yyyy ): ________________ Place of Birth ( city, state, country ): _____________________________ Gender: Male Female Social Security Number: ____________________ ** ** Providing your social security number (SSN) is mandatory, and requested under the authority granted by 42 U.S.C. §405(c)(2)(C). It will be used by the Departments of Taxes, Child Support, Labor and the Judiciary in the administration of Vermont law, to identify individuals affected by such laws. Your SSN is not disclosed as part of a public records request. For International Nurses who do not hold a Social Security number please provide a passport number, and attach a copy of your passport. Passport Number: _________________________ *** ***Provide passport information if the applicant does not have a social security number to provide evidence that there is no attempt to procure a license fraudulently (26 V.S.A. §1582 and 3 V.S.A. §129a) Home Telephone:_(___)___________________ Work Telephone: _(___)___________________ Cell Phone: _(___)_____________________ E-Mail Address: _______________________ (Continue to Next Page)
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Section B: Please circle Yes or No for each of these questions.
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