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Forms
General Forms & Applications
Credentials/Language Evaluation Services (LIC-616)
Request to Change Legal Name  (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
NURSYS License Verification Form
Presentation Request Form--Nurse Practice Act Presentations​
RN/LPN Forms & Applications
NCLEX Exam Application for US Graduates                            Help Link: How to Complete the Application
​NCLEX Exam Application for Non-US Graduates (LIC-103/103A-FOR)
NCLEX Exam Testing Accommodations Request Form (LIC-614)
Re-Examination Application (for NCLEX) (LIC-103B)
​Photo Identification for NCLEX Exam Eligibility (LIC-103A)
Endorsement Application for US Graduates                            Help Link: How to Complete the Application
Endorsement Application (Only for Graduates of Internationally-Based Nursing Programs)  (LIC-102/LIC-616)
​Limited License for Re-Entry (LIC-110)
Reactivation Application for RNs and LPNs (web-based)          Help Link: How to Complete the Application
​Reactivation Application for RNs, LPNs, and APRNs  (LIC-105)
Renewal Application for RNs, LPNs, and APRNs 
RNFA Registry Application
​Nurse Emeritus (LPN/RN) Application (LIC-115)
​Reapply for LPN/RN Nurse Emeritus Licensure (LIC-117)
Verification of Current State Licensure for Endorsements into Oregon (LIC-116B.  Use only for Alabama, California, Hawaii, Louisiana-LPN, Oklahoma, or Pennsylvania)
​​Verification of Original State Licensure for Endorsements into Oregon (LIC-116A.  Use only for Alabama, California, Hawaii, Louisiana-LPN, Oklahoma, or Pennsylvania)
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 (web-based)
CNA 1 Exam Application (LIC-703)         Help Link:  ​How to Complete the Application
CNA 1 Exam Testing Accommodations Request Form (LIC-614)
List of CNA Registries by State
​Re-Examination Application (LIC-703B)
Reactivation Application for CNA1 or CMA  (LIC-701)
​Renewal Application for CNAs and CMAs
Application for CNA Certification Using Nursing Education (LIC-705)
​CNA State Certificate Verification for Endorsements into Oregon (LIC-711)
Verification of Oregon CNA/CMA Request Form (LIC-625)
Advanced Practice Forms
​APRN Pharmacological Management Evaluation Form, Part A
APRN Pharmacological Management Evaluation Form, Part B
CNS Application Packet (LIC-206)
CRNA Application (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 
​CRNA Renewal Application with Removal of Prescriptive Authority (LIC-214)
NA/MA Education Forms
LPN Clinical Preceptor Guidelines ​​(For NA/MA Programs)
Application for Designated Faculty of an NA/MA/CNA 2 Training Program (EDU-735) 
Application To Provide an NA/MA/CNA 2 Training Program (EDU-730)
RN/LPN Education Forms
Candidate List for PN/RN Nursing Program Graduates
Re-Entry Preceptor Application (Word)
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