For payment, you can use credit or debit American Express, Discover, Visa, MasterCard, or you may pay from your checking or savings account.

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? YESNO

*Q. 2) Are you a member of the United States Armed Forces on federal active duty and deployed overseas? YESNO

*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.)

Kentucky Board of Nursing