Registration Form

Please do NOT use a comma ‘,’ or semi-colon ‘;’ while entering your information


FIRST NAME:      MIDDLE INITIAL: LAST NAME:

LICENSURE  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!


Check agreement box, initial, sign, then submit.

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