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License Information
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Primary Work License Type
Work License Type
Registered Nurse (RN)
License Nurse Practitioner (LPN)
Certified Nurse Assistant (CNA)
Clinical Nurse Specialist (CNS)
Certified Nurse Midwife (CNM)
Certified Registerd Nurse Anesthetist (CRNA)
(RN, LPN, CNA, CNS, CNM, CRNA, NP, PA)
License Expiration Date
State Issued
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Active and primary license issuing state.
License Number
Is this an eNLC license?
Yes
No
Work Authorization and Photo ID Information
Do you have the legal right to work in the US?
Yes
No
Do you need visa sponsorship?
Yes
No
Photo ID
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Photo ID Type
Select a Photo ID type
US Passport
Green Card/Permanent Residency
Foreign Passport
Driver's License
School ID
State ID
ID Expiration Date
ID Number
Date of Birth
Gender
Select Gender
Male
Female
Other / Non binary
Gender as mentioned in the Photo ID.
Issuing Authority
Training and Medical Information
TB Exam Document
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You can upload up to 2 files.
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TB Screening
TB Type
Stage 1
Stage 2
X-Ray Chest
Questionnaire
TB Exam Expiration Date
TB Test Date
CPR Training Document
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CPR Type
CPR Type
American Heart Association
American Red Cross
Other
CPR Expiration Date
CPR Issue Date
Physical Exam Document
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You can upload up to 2 files.
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Physical Exam Expiration Date
Physical Exam Certificate Issue Date
Flu Shot Document
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Flue Shot Expiration Date
Flu Shot Completion Date
Tax and Banking Information
Tax and Banking Documents
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Documents Uploaded
Federal
State W-4
SSN Document
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Social Security Number
Emergency Contact
Emergency Contact Name
*
First
Last
Emergency Contact Relationship
Emergency Contact Phone Number
Miscellaneous Document
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Additional Comments
Name
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