Nurses and Prescribing - Minnesota 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Applicant Information' section. Enter your last name, first name, and middle name (if applicable). If you have no middle name, check the corresponding box.
3. Provide your street address, city, state (Minnesota), zip code, and country. Ensure all information is accurate and clearly typed or printed.
4. Enter your Minnesota license number and birth date in the specified format (mm/dd/yyyy). Select your gender by marking either 'Male' or 'Female'.
5. Fill in your email address and type of practice. Indicate the last date of nursing practice using the mm/dd/yyyy format.
6. Sign and date the form at the bottom of this section to confirm that all information provided is true and complete.
7. Send this form to an employer or contractor for verification. Ensure they complete their section accurately before submission.

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