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Application for Nurse Practitioner (NP) Certification

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GOVERNOR GAVIN NEWSOM BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 | Application FOR Nurse Practitioner (NP) Certification Application FEE -$ PERSONAL DATA (PRINT OR TYPE)MILITARY HONORABLE DISCHARGE -Check here if you served as an active duty member of the Armed Forces of the United States and were honorably discharged.

information provided in connection with this application for licensure is true, correct and complete. Providing false information or omitting required information is grounds for denial of licensure or license revocation in California. _ Attach a recent 2”x2” passport type photograph. Please tape on all four sides. Head and shoulders only

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