North carolina division of health service regulation 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your RN or LPN information. Clearly type or print your name as listed on your nursing license, along with your maiden name and full social security number.
3. Provide your RN/LPN license number, mother’s maiden name, date of birth, and state of issuance. Select your license type (RN or LPN) and if you are a new graduate, include the date of graduation.
4. Fill in your mailing address, including street or PO Box, city, state, and zip code. Also, provide both home and work telephone numbers along with your email address.
5. Indicate whether you have ever been listed on the NC Nurse Aide I Registry by selecting YES or NO. If applicable, include your NC Listing number.
6. Sign the form to authorize the verification of your license. This step is crucial for processing your application.
7. If required, attach any recommendation letters before submitting the completed application via fax or mail to the provided address.

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