Kentucky Board of Nursing


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RN License #
 
SSN# (Last Four Digits)
 
Date of Birth
Month   Day   Year  
I declare my state of primary residence to be:
 
Do you practice nursing ONLY in a military/federal facility:
 
US Armed Forces
*Q. 1) Are you a member of the United States Armed Forces on active duty?  
 
*Q. 2) Are you a member of the United States Armed Forces on federal active duty and deployed overseas?  
 
*Q. 3) Branch of active duty service  
 
ATTESTATION STATEMENT
  • I am the person referred to in the foregoing application;
  • I am not delinquent in repayment of a defaulted Nursing Incentive Scholarship Fund award administered by KBN;
  • I have met or will have met the continuing competency requirement by October 31 of the current year;
  • I have read and understand this application and all requirements stated therein;
  • I declare my primary state of residence to be the state indicated in the Declaration of Primary Residence section of this application; and
  • I understand that all information on this application is subject to verification and that knowingly supplying false information on or with this application is a violation of KRS Chapter 314 and may subject me to disciplinary action.
   

(Service fee for ACH payments is a flat $1.00 transaction fee and for a credit card is 2.75% transaction fee. Service fees are calculated on the next page.)