* Required Information
PROFESSIONAL INFORMATION
Professional license
Effective Date(s)
Registry or certification
Effective Date(s)
Out or State Licenses
Is registration or licensing pending?
To your knowledge, are you currently the subject of a complaint or are you under investigation by any professional licensure or registration body (such as a State Attorney Grievance Commission or a State Board of Nursing?)
Yes
No
Please note below all details known to you regarding this complaint or investigation:
Has your license ever been suspended or revoked or have you otherwise been reprimanded, disciplined or sanctioned by any professional licensure or registration body?
Yes
No
Please explain
Are you currently the subject of any criminal or other charges that could affect your license or registration to practice in your profession if found mentorious.
Yes
No
Please explain
Is any non-complete, non-solicitation, non-disclosure, or similar agreement applicable to your current activities?
Yes
No
Attach copy of the agreement to this application
WILL VERIFY ALL NURSING LICENSES THROUGH MARYLAND BOARD OF NURSING (MBON)
Name of Applicant:
*
Date:
*
Submit
Form 3/5