Registration Form Please do NOT use a comma ‘,’ or semi-colon ‘;’ while entering your information FIRST NAME: MIDDLE INITIAL: LAST NAME: LICENSURE RNLVNAPRN Number: DOB: Ex: 2011-01-30 [If no Nursing License#, blank out Licensure and only check below SN box and Enter your SSN#SN: SSN: [ Last 4 numbers only ] ? (hover over question mark) CLINICAL PRACTICE: YEARS OF EXPERIENCE: MALE FEMALE RACE CAUCASIAN AFRO-AMERICAN HISPANIC ASIAN [ OTHER Specify: ] ADDRESS: CITY: STATE:ZIP: HOME PHONE: –– MOBILE PHONE: –– EMAIL ADDRESS: CLASSES (To select another class, click the down arrow next to the class and select date of choice) If no dates appear below, refresh 2-3 times If no dates appear below, refresh 2-3 times OVERVIEW OF TEXAS NURSING – Legal and Foundation of Nursing DATE: Year-Month-Day DOCUMENT AND REPORTING DATE: Year-Month-Day AGREE TO OUR TERMS? Click box to agree See terms and conditions. Initials: Signature area (Mouse click and hold the click, then proceed to sign your name. Click save then submit): Signature instructions using Smart Devices(ie Phone/Tablet) (Hold finger still on signing area for 2 secs and proceed to sign your name in VERY VERY slow motion): Stay within border – Thanks! Your browser does not support inline frames or is currently configured not to display inline frames. Check agreement box, initial, sign, then submit.