Transcription of Louisiana State Board of Nursing - LSBN
1 Louisiana State Board of Nursing 17373 perkins Road Baton Rouge, LA 70810 Telephone: (225) 755-7500 Fax: (225) 755-7582 REQUEST FOR PUBLIC RECORD DISCIPLINARY INFORMATION I am requesting the public record disciplinary history of an individual with the Board of Nursing Information of Individual with Disciplinary Action: Full Name: RN License or Permit Number (if known): Social Security Number (if known): Other Identifying Information, if any: Contact Information of Requestor: Business: Full Name: Current Address: City/ State /Zip: Home Phone: ( ) Work Phone: ( ) Cell or Alternate phone: ( _ _) Fax: ( ) Email: NOTE: This form must be mailed to the Board with a payment of $ (We do not accept cash, personal checks or credit cards) Revised 09/07/07,05/01/08, 03/25/15
