Form 08-4016 - Application For Registered Nurse By Endorsement - 2000
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3NUR
FOR OFFICE USE ONLY
ALASKA BOARD OF NURSING
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
STATE OFFICE BUILDING
333 WILLOUGHBY AVENUE, 9TH FLOOR
P.O. BOX 110806, JUNEAU, ALASKA 99811-0806
Fax (907) 465-2974
E-mail: license@dced.state.ak.us
If your last name begins with A-K, call (907) 465-2544
If your last name begins with L-Z, call (907) 465-2648
APPLICATION FOR REGISTERED NURSE BY ENDORSEMENT
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$ 50.00
Nonrefundable Application Fee
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$ 215.00
License Fee
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$ 50.00
Temporary Permit Fee
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TEMPORARY PERMIT:
YES
NO
Enclose a check or money order payable to the STATE OF ALASKA for $265.00 or $315.00 if you want a
temporary permit.
Name:
Last
First
Middle
Other Names:
Maiden and/or Other
Mailing Address:
Street Address or P.O. Box
City
State
Zip Code
Mailing Address for Temporary Permit:
Social Security Number:
Required by AS 08.01.060. (The department is not
authorized to issue a license unless the applicant’s Social Security Number is provided. If you are a foreign citizen unable
to obtain a U.S. Social Security Number, contact the division for further instructions.)
Date of Birth:
Sex:
Telephone Number (Day):
+
q
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Have you ever been issued an RN license in Alaska?
Yes
No
DO NOT SUBMIT THIS FORM IF YOU ANSWERED “YES.” YOU NEED TO APPLY
FOR REINSTATEMENT AND YOU ARE NOT ELIGIBLE FOR A TEMPORARY PERMIT.
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NURSING EDUCATION: Type of Program:
Diploma
Associate Degree
Baccalaureate
Generic Masters
Name of School of Nursing
City and State
Dates Attended
Date of Graduation
ADDITIONAL EDUCATION: (Nursing Courses taken after basic program)
Name of Institution/Address
Name of Program
Dates of Attendance
FOR OFFICE USE ONLY
T.P. No.:
Expiration Date:
Issued By:
08-4016 (Rev. 8/00)
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