Text Size:   A+ A- A   •   Text Only
Find     
Site Image

Forms
Download Adobe Reader Here
Download Latest Version of Adobe Reader (Free Download)
General Forms & Applications
Credentials/Language Evaluation Services (LIC-616)
Change of Name/Address Request  (OSBN-613)
Complaint Form
Facility Credit Card Authorization Form
Fingerprint Verification Form  (LIC-618)
Inactive/Retired Status Application Form  (LIC-615)
Issue Review Request Form
Limitation of Liability for Practice
Mailing List Request Form (OSBN-619)
Map to OSBN Office
Non-Oregon Based Programs Offering Clinical Experience in Oregon
NURSYS License Verification Form
Presentation Request Form--Nurse Practice Act Presentations​
RN/LPN Forms & Applications
NCLEX Exam Application (LIC-103/103A)
NCLEX Exam Testing Accommodations Request Form (LIC-614)
Re-Examination Application (for NCLEX) (LIC-103B)
Endorsement Application for US Graduates (Online system)
​Endorsement Application for US Graduate (paper form-LIC-102)
Endorsement Application for Non-US Grads  (LIC-102/LIC-616)
​Limited License for Re-Entry (LIC-110)
​Reactivation Application for RNs, LPNs, and APRNs  (LIC-105)
Renewal Application for RNs, LPNs, and APRNs  (LIC-101)
RNFA Registry Application
​Nurse Emeritus Application (LIC-115)
​Verification of Current State Licensure for Endorsements into Oregon (Use only for Alabama, California, Hawaii, Kansas, Louisiana-LPN, Oklahoma, Pennsylvania, or West Virginia-RN)
​​Verification of Original State Licensure for Endorsements into Oregon (Use only for Alabama, California, Hawaii, Kansas, Louisiana-LPN, Oklahoma, Pennsylvania, or West Virginia-RN)
CNA/CMA Forms & Applications
CMA Continuing Education form (extra)
CMA Exam Application Packet (LIC-704)
Application for CNA/CMA Certification by LPN/RN Licensure (LIC-706)
​CNA1 Authorized Duties Competency Evaluation Form (EDU-720)​
CNA2 Authorized Duties Competency Evaluation Form (EDU-721)
CNA 1 Endorsement Application Packet (LIC-702)
CNA 1 Exam Application (LIC-703)
CNA 1 Exam Testing Accommodations Request Form (LIC-614)
List of CNA Registries by State
​Re-Examination Application (LIC-703B)
Renewal/Reactivation Application for CNA1 or CMA  (LIC-701)
Application for CNA Certification by Student Nurse Education (LIC-705)
Advanced Practice Forms
​APRN Pharmacological Management Evaluation Form, Part A
APRN Pharmacological Management Evaluation Form, Part B
CNS Application Packet (LIC-206)
Continuing Education Documentation Form
CRNA Application Packet (LIC-205)
Dispensing Authority Application  (LIC-201)
DEA Address Change Form
DEA Duplicate Certificate Request Form
DEA Schedule Change Requests
Malpractice/Negligence Claim Report Form
National Provider Identifier
Nurse Practitioner Application Packet (LIC-203 & 204)
Prescriptive Authority Application​ for APRNs (LIC-204)
Reactivation Application for RNs, LPNs, and APRNs  (LIC-105)
Renewal Application for RNs, LPNs, and APRNs  (LIC-101)
NA/MA Education Forms
LPN Clinical Preceptor Guidelines ​​(For NA/MA Programs)
NA, MA and Level-2 Instructor Application 
NA/MA/CNA2 Training Program Application
RN/LPN Education Forms

Nursing Faculty Appointment Form (Word)

Candidate List for PN/RN Nursing Program Graduates
Re-Entry Preceptor Application (Word)