INSTRUCTIONS AND REQUIREMENTS FOR REINSTATEMENT / REACTIVATION SOUTH CAROLINA ADVANCED PRACTICE REGISTERED NURSE (APRN) LICENSE

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1 INSTRUCTIONS AND REQUIREMENTS FOR REINSTATEMENT / REACTIVATION SOUTH CAROLINA ADVANCED PRACTICE REGISTERED NURSE (APRN) LICENSE Infrmatin fr Applicant Suth Carlina is a member f the Nurse Licensure Cmpact (NLC). The NLC des nt affect additinal requirements impsed by states fr advanced-practice registered nursing. A multi-state licensure privilege t practice registered nursing granted by a party state must be recgnized by ther party states as a license t practice registered nursing if a license t practice registered nursing is required by state law as a precnditin fr qualifying fr advanced-practice registered nurse authrizatin. A current Suth Carlina APRN license r temprary license is required t practice advanced nursing in this state. Orientatin is cnsidered the practice f nursing in Suth Carlina. Therefre, all nurses must pssess a current Suth Carlina license and/r temprary license befre beginning rientatin (including classrm instructin and reading plicies and prcedures). It is a vilatin f the Nurse Practice Act t begin rientatin withut the prper license and can result in actin by the Bard. Please visit ur website at t review the cmplete Suth Carlina Nurse Practice Act, Chapter 33, Sectin fr mre details n educatinal and certificatin requirements. Suth Carlina Nurse Practice Act Definitins. (31) "Inactive license" means the fficial temprary retirement f a persn's authrizatin t practice nursing upn the persn's ntice t the bard that the persn des nt plan t practice nursing r the status f a license that des nt currently authrize a licensee t practice nursing in this State. (34) "Lapsed license" means the terminatin f a persn's authrizatin t practice nursing due t the persn's failure t renew his r her nursing license within the renewal perid. The Bard may reinstate/reactivate an APRN licensee frm inactive/lapsed status upn payment f reactivatin/ reinstatement fee and furnish evidence satisfactry that applicant has met requirements fr licensure as prvided in An applicant fr licensure as an Advanced Practice Registered Nurse (APRN) shall furnish evidence satisfactry t the bard that the applicant: (1) has met all qualificatins fr licensure as a registered nurse; and (2) hlds current specialty certificatin by a bard-apprved credentialing rganizatin. New graduates shall prvide evidence f certificatin within ne year f prgram cmpletin; hwever, psychiatric clinical nurse specialists shall prvide evidence f certificatin within tw years f prgram cmpletin; and (3) has earned a master's degree frm an accredited cllege r university, except fr thse applicants wh: (a) prvide dcumentatin as requested by the bard that the applicant was graduated frm an advanced, rganized frmal educatin prgram apprpriate t the practice and acceptable t the bard befre December 31, 1994; r (b) graduated befre December 31, 2003, frm an advanced, rganized frmal educatin prgram fr nurse anesthetists accredited by the natinal accrediting rganizatin f that specialty. CRNA's wh graduate after December 31, 2003, must graduate with a master's degree frm a frmal CRNA educatin prgram fr nurse anesthetists accredited by the natinal accreditatin rganizatin f the CRNA specialty. An advanced practice registered nurse must achieve and maintain natinal certificatin, as recgnized by the bard, in an advanced practice registered nursing specialty; (4) has paid the bard all applicable fees; and

2 (5) has declared specialty area f nursing practice and the specialty title t be used must be the title which is granted by the bard-apprved credentialing rganizatin r the title f the specialty area f nursing practice in which the nurse has received advanced educatinal preparatin. Prescriptive Authrity: APRN s applying fr prescriptive authrity shall meet the requirements as nted in the S.C. Nurse Practice Act, Sectin (E). In rder t change the status f yur license frm Inactive/Lapsed Status t Active Status, yu must d the fllwing: Cmplete and submit the APRN reinstatement/reactivatin applicatin and if applicable, Prescriptive Authrity applicatin. Applicatin fees are nn-refundable. Mney rder, cashier s check r persnal check shuld be made payable t LLR-Bard f Nursing. Yur applicatin must include the fllwing: 1. Cmplete the Affidavit f Eligibility 2. Cmplete the Criminal Backgrund prcess. 3. Recent 2 x 2 full faced passprt type pht, sign and date n frnt r back and tape alng tp edge nly nt yur applicatin. 4. Cpy f yur current state license 5. Cpy f current specialty certificatin by a bard-apprved credentialing rganizatin. 6. Cpies f legal dcuments that authrize a change in name, if applicable. 7. Obtain all physician signatures and license numbers t be included n yur applicatin, if applicable. 8. See the SC Nurse practice Act fr guidelines n the develpment f written prtcls. 9. If applying fr Prescriptive Authrity, cmplete and submit the fllwing: Prescriptive Authrity Applicatin and dcumentatin f cntinuing educatin hurs in pharmactherapeutics 10. Applicatin fees Mney rder, cashier s check r persnal check made payable t LLR-Bard f Nursing. APRN Reinstatement f lapsed license $90.00 APRN Reinstatement f lapsed license with Prescriptive Authrity $ APRN Reactivatin f inactive license $70.00 APRN Reactivatin f inactive license with Prescriptive Authrity $90.00

3 Criminal Backgrund Check (CBC) Effective March 2, 2009, an applicant fr a license t practice nursing in Suth Carlina shall be subject t a criminal histry backgrund check as defined in f the Nursing Practice Act. This prcess requires yu t furnish a full set f fingerprints and additinal infrmatin required t enable a criminal histry backgrund check t be cnducted by the State Law Enfrcement Divisin (SLED) and the Federal Bureau f Investigatin (FBI). These services are prvided by IdentGO Centers and are perated by MrphTrust USA. Residents f Suth Carlina shuld g nline t schedule fr fingerprinting services: r call (866) fr assistance in scheduling. Scheduling services will prvide detailed infrmatin f frms f identificatin that will be required. If yu are a nn-resident f Suth Carlina and d nt reside in an area near Suth Carlina, please fllw the Nn- Resident Card Scan Prcessing Prcedures belw. Nn-Resident Card Scan Prcessing Prcedures Fr applicants that reside ut f Suth Carlina wh wish t use the IdentGO/Mrph Trust USA Centers, yu may use these centers that are lcated in Suth Carlina nly. If an applicant des nt reside near Suth Carlina, they must cmplete and submit the fingerprint cards by fllwing the directins belw. This prgram utilizes advanced scanning technlgy t cnvert a traditinal fingerprint card (hard card) int an electrnic fingerprint recrd. The sectin belw details the prcedures fr submitting fingerprints t the MrphTrust card scan department. Applicant shuld cntact IdentGO/MrphTrust ( ) t verify the current fee t submit. Applicants shuld btain a set f fingerprints frm a lcal law enfrcement agency r ther entity that prvides fingerprinting services. These fingerprint cards may be either traditinal ink rlled fingerprints r electrnically captured and printed fingerprint cards. Fingerprints may be submitted n FBI applicant cards. The applicant may call r the Nursing Bard t have the FBI applicant cards mailed t them. Phne: r nursebard@llr.sc.gv. Due t agency specific infrmatin, MrphTrust USA des nt prvide fingerprint cards t applicants. Applicant shuld ensure the fingerprint cards are cmpletely filled ut. Required infrmatin includes: ORI Number: SC920112Z Full Name Hme Address Place f Birth (State r Cuntry Only) Citizenship Scial Security Number Date f Birth Sex, Height, Weight, Hair Clr and Eye Clr Reasn fingerprinted Mail the fully cmpleted card and applicable fee (Include full name f applicant n the check) t: IDENTOGO CARDSCAN DEPARTMENT 6840 CAROTHERS DRIVE STE 650 FRANKLIN, TN Fllw-up calls and questins n the prcessing f a fingerprint card shuld be made directly t IdentGO/MrphTrust at (866) and speak t a custmer service representative. DO T return fingerprint card r fingerprint prcessing fee in with yur applicatin r t the Bard f Nursing. This will delay the prcessing f yur applicatin.

4 NCRIMINAL JUSTICE APPLICANT S PRIVACY RIGHTS As an applicant wh is the subject f a natinal fingerprint-based criminal histry recrd check fr a nncriminal justice purpse (such as an applicatin fr a jb r license, an immigratin r naturalizatin matter, security clearance, r adptin), yu have certain rights which are discussed belw. Yu must be prvided written ntificatin 1 that yur fingerprints will be used t check the criminal histry recrds f the FBI. If yu have a criminal histry recrd, the fficials making a determinatin f yur suitability fr the jb, license, r ther benefit must prvide yu the pprtunity t cmplete r challenge the accuracy f the infrmatin in the recrd. The fficials must advise yu that the prcedures fr btaining a change, crrectin, r updating f yur criminal histry recrd are set frth at Title 28, Cde f Federal Regulatins (CFR), Sectin If yu have a criminal histry recrd, yu shuld be affrded a reasnable amunt f time t crrect r cmplete the recrd (r decline t d s) befre the fficials deny yu the jb, license, r ther benefit based n infrmatin in the criminal histry recrd. 2 Yu have the right t expect that fficials receiving the results f the criminal histry recrd check will use it nly fr authrized purpses and will nt retain r disseminate it in vilatin f federal statute, regulatin r executive rder, r rule, prcedure r standard established by the Natinal Crime Preventin and Privacy Cmpact Cuncil. 3 If agency plicy permits, the fficials may prvide yu with a cpy f yur FBI criminal histry recrd fr review and pssible challenge. If agency plicy des nt permit it t prvide yu a cpy f the recrd, yu may btain a cpy f the recrd by submitting fingerprints and a fee t the FBI. Infrmatin regarding this prcess may be btained at If yu decide t challenge the accuracy r cmpleteness f yur FBI criminal histry recrd, yu shuld send yur challenge t the agency that cntributed the questined infrmatin t the FBI. Alternatively, yu may send yur challenge directly t the FBI. The FBI will then frward yur challenge t the agency that cntributed the questined infrmatin and request the agency t verify r crrect the challenged entry. Upn receipt f an fficial cmmunicatin frm that agency, the FBI will make any necessary changes/crrectins t yur recrd in accrdance with the infrmatin supplied by that agency. (See 28 CFR thrugh ) 1 Written ntificatin includes electrnic ntificatin, but excludes ral ntificatin. 2 See 28 CFR 50.12(b). 3 See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 42 U.S.C , Article IV(c); 28 CFR 20.21(c), 20.33(d) and 906.2(d).

5 APRN REINSTATEMENT/ REACTIVATION APPLICATION Check all that apply: Reinstatement Reactivatin Prescriptive Authrity Suth Carlina is a member f the Nurse Licensure Cmpact (NLC). Advanced practice is recgnized as a single state license nly. Please visit fr mre infrmatin r fr a current list f Cmpact States. Please print. Answer all questins and submit with prper fee. Careful cmpletin f this applicatin will avid a delay in prcessing. Persnal infrmatin prvided in this applicatin may be subject t public scrutiny r released under the SC Freedm f Infrmatin Act r ther prvisins f federal and state law. The Scial Security Number (SSN) is nt subject t disclsure as public infrmatin. The disclsure f the SSN fr identificatin purpses is authrized and mandated by federal statutes requiring state bards t reprt t the Natinal Practitiner Data Bank (NPDB), amng ther things. The Suth Carlina Cde f Laws requires that every individual wh applies fr an ccupatinal r prfessinal license prvide a scial security r alien identificatin number fr use in the establishment, enfrcement and cllectin f child supprt bligatins and fr reprting t certain databanks established by law. Failure t prvide yur scial security number fr these mandatry purpses will result in the denial f yur licensure applicatin. Scial security numbers may als be disclsed t ther gvernmental regulatry agencies and fr identificatin purpses t testing prviders and rganizatins invlved in prfessinal regulatin. Yur scial security number will nt be released fr any ther purpse nt prvided fr by law. Scial Security Number: - - Full Legal Name: Mailing Address: Hme Address: Cunty: First Middle Maiden (if married) Last Street/PO Bx City State Zip Street (physical address required) City State Zip Address: Telephne #: Date f Birth: Place f Birth: Race: (fr statistical purpses nly) American Indian African American Caucasian Hispanic Oriental/Asian Other Marital Status: Single Married Widwed Divrced Sex: Female Male Declaratin f Primary State f Residence: (where I hld a driver s license, pay taxes r vte) I declare my primary state f residence is I plan t primarily practice in the state f I am in the military r federal gvernment. I am currently licensed in (state) and I d nt intend t wrk utside f military r federal gvernment. Remit fee by mney rder, cashier check r persnal check, made payable t LLR-Bard f Nursing with applicatin. Fr a legal name change, include dcumented prf (required- marriage license, divrce decree r curt dcument). The applicatin fee is nnrefundable. Check nly ne bx belw. APRN Reinstatement f lapsed license $90.00 APRN Reinstatement f lapsed license with Prescriptive Authrity $ APRN Reactivatin f inactive license $70.00 APRN Reactivatin f inactive license with Prescriptive Authrity $90.00 Attach riginal recent 2 x 2 passprt pht Sign and date pht n left side Tape n tp edge nly D nt staple

6 Name Persnal Histry Infrmatin If yu answer yes t any f the questins belw (1-10), yu must attach a full written explanatin pertaining t that particular questin. 1. Have yu ever had any applicatin fr any prfessinal license, certificatin, r registratin refused r denied by any licensing authrity? 2. Have yu ever been refused r denied the privilege f taking an examinatin required fr any prfessinal license? 3. Have yu ever been the subject f disciplinary actin with regard t a license, been revked r sanctined by any licensing authrity, assciatin, licensed facility, r staff f such facility? 4. Have yur privileges ever been restricted r terminated by any assciatin, licensed facility, r staff f such facility; r have yu ever vluntarily r invluntarily resigned r withdrawn frm such assciatin r facility t avid impsitin f such measures? 5. T yur knwledge have any unreslved r pending cmplaints ever been filed against yu with any federal r state agency, prfessinal assciatin, licensed hspital r clinic, r staff f such hspital r clinic? 6. Have yu ever been arrested, charged r cnvicted (including a nl cntender plea r guilty plea) in any state r federal curt (ther than minr traffic vilatins) whether r nt sentence was impsed r suspended? If yes, attach a certified cpy f the curt recrds regarding yur cnvictin, the nature f the ffense, date f discharge, if applicable, as well as a statement frm the prbatin r parle fficer sent directly t the Bard frm the abve-mentined authrities. 7. Currently are yu being treated r within the last five years, have yu been treated fr drug r alchl addictin that might interfere with yur ability t cmpetently and safely perfrm the essential functins f practice? 8. Currently r within the last five years, have yu been treated fr any physical, mental r emtinal cnditin that might interfere with yur ability t cmpetently and safely perfrm the essential functins f practice? 9. Currently r within the last five years, have yu develped any disease r cnditins, physical, mental, r emtinal that might interfere with yur ability t cmpetently and safely perfrm the essential functins f practice? 10. a. Have yu ever vluntarily surrendered a nursing license? b. Have yu ever vluntarily surrendered a cntrlled substance r DEA registratin? 11. a. D yu plan t prescribe Schedules III thrugh V? b. D yu have a cntrlled substance r DEA registratin? Specialty Area(s) & Certificatin(s) NA NA NA 1. Specialty area f APRN practice. 2. Describe yur specialty area in advanced nursing practice. (This sectin will be assessed by an Advanced Practice Nursing Cnsultant wh will determine the clsest scpe f practice area in accrdance with Natinal Certificatin) 3. D yu hld current specialty certificatin by a natinal credentialing rganizatin(s)? Certifying Organizatin Expiratin date (Attached a cpy f certificate) Other Check here if yu are trained and willing t vlunteer yur services during a biterrrism disaster? Check here if yu are trained and willing t vlunteer yur services during a disaster?

7 Name Advanced Practice Emplyment (Current) PRIMARY Practice Site (If mre than 2 sites, duplicate frm as needed) Emplyer Name (Use blank cpies f this frm t add multiple practice sites and/r physicians): Practice Address: (Street, City, State, Zip Cde) * Supervising Physician: Primary Physician Alternate Supervising Physician Supervising Physician (All physicians must have a permanent SC license in gd standing) Business Address: (Street, City, State, Zip) Prximity t NP, CNM, CNS in Miles: SC Physician s License N: Practice Specialty: Primary Practice Site Phne Number Signature f Supervising Physician * Date SECONDARY/ADDITIONAL Practice Site (If mre than 2 sites, duplicate frm as needed) Emplyer Name: Practice Address: (Street, City, State, Zip) * Supervising Physician: Primary Physician Alternate Supervising Physician Supervising Physician (All physicians must have a permanent SC license in gd standing) Business Address: (Street, City, State, Zip) Prximity t NP, CNM, CNS in Miles: SC Physician s License N: Practice Specialty: Secndary Practice Site Phne Number Signature f Supervising Physician * Date A cpy f practice prtcls, fr NP, CNM, r CNS/ cpy f written apprved guidelines fr CRNA signed and dated by all the physicians listed abve and myself are n file in the ffice/agency f my emplyment and available upn request. * Nte: Pursuant t (H)(2)(a)(ii), in additin t the supervising physician r dentist, CRNAs may als have the physician directr f anesthesia services r the medical directr f the facility sign this frm.

8 Name I,, am the persn described and identified, f gd mral character, and the persn named in all dcuments presented in supprt f this applicatin. I have carefully read the questins in the freging applicatin and have answered them cmpletely, withut reservatins f any kind and I declare that all statements made by me herein are true and crrect. Shuld I furnish any false r incmplete infrmatin in this applicatin, I hereby agree that such act shall cnstitute the cause fr denial r revcatin f my license t practice in Suth Carlina. Signature f applicant (d nt print) Date Printed name f applicant (first, middle, maiden, last) Subscribed and swrn befre me this day f, (Signature f ntary public) My cmmissin expires Remember t: Cmplete and answer all questins; Sign, date and have yur applicatin ntarized Cmplete the Affidavit f Eligibility Cmplete the Criminal Backgrund prcess Recent 2 x 2 full faced passprt type pht, sign and date n frnt r back and tape alng tp edge nly nt yur applicatin Cpy f yur current state license, ther than SC Cpy f current specialty certificatin by a bard-apprved credentialing rganizatin Cpies f legal dcuments that authrize a change in name, if applicable Obtain all physician signatures and license numbers t be included n yur applicatin, if applicable. See the SC Nurse Practice Act fr guidelines n the develpment f written prtcls. If applying fr Prescriptive Authrity, please cmplete and submit the fllwing: Prescriptive Authrity Applicatin and certificates f cntinuing educatin hurs in pharmactherapeutics (see statute fr specific guidelines). Cmplete the requirements fr the criminal backgrund check Prvide prf f residence- cpy f driver s license r vter registratin card Once all requirements have been met, yur license may be reactivated r reinstated within 10 business days. During peak times, the applicatin review/apprval prcess may take lnger.

9 STATE OF SOUTH CAROLINA DEPARTMENT OF LABOR, LICENSING AND REGULATION VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES AFFIDAVIT OF ELIGIBILITY Pursuant t Sectin , et seq. f the Suth Carlina Cde f Laws (1976, as amended), the Department f Labr, Licensing and Regulatin must verify that any persn wh applies fr a Suth Carlina license is lawfully present in the United States. Cmplete and sign this affidavit f eligibility. The infrmatin prvided is subject t verificatin. Sectin A: LAWFUL PRESENCE in the United States. The undersigned, f (Print clearly First, Middle, and Last name) (Hme Address, City, State, and Zip Cde) being first duly swrn depses and states as fllws: Check nly ne bx: 1. _I am a United States citizen; r 2. _I am a Legal Permanent Resident f the United States eighteen years f age r lder; r 3. _I am a Qualified Alien r nn-immigrant under the Federal Immigratin and Natinality Act, Public Law , eighteen years f age r lder, and lawfully present in the United States. 4. _Other: Please submit any dcumentatin that supprts this status. Date f Birth: Alien Number: I-94 Number: (If yu checked number 2, 3, r 4 yu must attach a cpy f yur immigratin dcuments. See Instructin sheet fr a list f accepted immigratin dcuments.) Sectin B: ATTESTATION. I understand that in accrdance with sectin f the Suth Carlina Cde f Laws, a persn wh knwingly and willfully makes a false, fictitius, r fraudulent statement r representatin in an affidavit shall, in additin t ther sanctins impsed by this State r the United States, be guilty f a felny, and upn cnvictin must be fined and/r imprisned fr nt mre than 5 years (r bth). I understand that the representatins made in this Affidavit shall apply thrugh any license(s) r renewals issued, and that I shall have an affirmative duty t immediately advise the Department f Labr, Licensing and Regulatin f any change f my immigratin r citizenship status. I swear and attest the infrmatin cntained herein is true and crrect t the best f my knwledge. I understand that under Suth Carlina law, prviding false infrmatin is grunds fr denial, suspensin, r revcatin f a license, certificate, registratin r permit. Signature f Affiant SWORN t befre me this day f Ntary Public fr My Cmmissin Expires:

10 I INSTRUCTION SHEET FOR COMPLETING AFFIDAVIT OF ELIGIBILITY CHECK bx 1: If yu are a United States Citizen by birth r naturalizatin CHECK bx 2: If yu are a Legal Permanent Resident and yu are nt a U.S. Citizen, but are residing in the U.S. under legally recgnized and lawfully recrded permanent residence as an immigrant. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. CHECK bx 3: If yu are a Qualified Alien. Yu are a Qualified Alien if yu are: An alien wh is lawfully admitted fr residence under the INA. An alien wh is granted asylum under Sectin 208 f the INA. A refugee wh is admitted t the United States under Sectin 207 f the INA. An alien wh is parled int the United States under Sectin 212(d)(5) f the INA fr a perid f at least 1 year. An alien whse deprtatin is being withheld under Sectin 243(h) f the INA (as in effect prir t April 1, 1997) r whse remval has been withheld under Sectin 241(b)(3). An alien wh is granted cnditinal entry pursuant t Sectin 203(a)(7) f the INA as in effect prir t April 1, An alien wh is a Cuban/Haitian Entrant as defined by Sectin 501(e) f the Refugee Educatin Assistance Act f An alien wh has been battered r subjected t extreme cruelty, r whse child r parent has been battered r subject t extreme cruelty. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. ACCEPTED IMMIGRATION DOCUMENTS: Unexpired Reentry Permit (I-327) Permanent Resident Card r Alien Registratin Receipt Card With Phtgraph (I-551) Unexpired Refugee Travel Dcument (I-571) Unexpired Emplyment Authrizatin Card Which Cntains a Phtgraph (I-688) Machine Readable Immigrant Visa (with Temprary I-551 Language) Temprary I-551 Stamp (n passprt r I-94) I-94 (Arrival/Departure Recrd) in Unexpired Freign Passprt I-20 (Certificate f Eligibility fr Nnimmigrant, F-1, Student Status) DS2019 (Certificate f Eligibility fr Exchange Visitr, J-1, Status)

11 APPLICATION FOR PRESCRIPTIVE AUTHORITY FEES/ REQUIREMENTS: $20 fee. Submit a check r mney rder payable t LLR SC Bard f Nursing. Incmplete applicatins will be returned. Fees are nnrefundable. T meet initial requirements fr prescriptive authrity, the applicant must prvide evidence f 45 cntact hurs f pharmactherapeutics. within the past tw years frm the date f the applicatin and at 15 hurs must be in cntrlled substances. Or, if the applicant is cming frm anther state with prescriptive authrity, 20 cntact hurs f pharmactherapeutics is needed and at least 15 hurs must be in cntrlled substances. See the SC Nurse Practice Act, Chapter 33, Sectin (E) fr details. Transcripts must be sent directly frm the university t the Bard f Nursing. * The Scial Security Number (SSN) is nt subject t disclsure as public infrmatin. The disclsure f the SSN fr identificatin purpses is authrized and mandated by federal statutes requiring state bard t reprt t the Healthcare Integrity and Prtectin Data Bank (HIPDB) and the Natinal Practitiner (NPDN), amng ther things. 1. Full Legal Name: Last First Middle Maiden 2. Mailing Address: Street City State Zip 3. Hme Phne: 4. Scial Security Number: 5 S.C. License N. 6. Practice Specialty: 7. Attach a cpy f current natinal certificatin. 8. Primary Practice /Agency: Phne: Address: Street City State Zip All physicians must have a permanent S.C. license which is in gd standing. By signing this dcument, I affirm that I will nt supervise any mre than three NPs, CNMs r CNSs at any given time withut prir apprval by the SC Bard f Nursing and SC Bard f Medical Examiners, pursuant t S.C. Cde Ann (C), (43) and (C). 9. Supervising Physician: S.C. License N. Business Address: Street City State Zip Practice Specialty: Cunty: Wrk Phne Signature f Supervising Physician Prximity t Nurse in Miles: (Attach Additinal Pages fr Additinal Practice Sites) Alternate Supervising Physician: S.C. License N. Business Address: Street City State Zip Practice Specialty: Cunty: Wrk Phne Signature f Supervising Physician Prximity t Nurse in Miles: (Attach Additinal Pages fr Additinal Practice Sites) I HEREBY swear/affirm the statements made in this applicatin t be TRUE t the best f my knwledge. Signature f Applicant Date