DECLARATION OF PRIMARY STATE OF RESIDENCE / STATES OF PRACTICE This is NOT an application for licensure. Complete this form only if you currently hold a Colorado RN or PN license. In order for Colorado to issue you a license, clarification is needed from you regarding your primary state of residency. Please complete the form and return to the Colorado State Board of Nursing. For additional information on the Nurse Licensure Compact go to www.ncsbn.org/nlc.htm Return the completed form to: State Board of Nursing, 1560 Broadway, Suite 1350, Denver, CO 80202, or you may fax this form to (303) 894-2821. Colorado RN / PN License Number:

License Expiration Date:

PART 1—LICENSEE INFORMATION First:

Name: Last: Social Security Number:

Middle:

Date of Birth (mm/dd/yyyy):

Primary Residence Physical Address:

Street:

(PO Boxes are not accepted)

City, State, Zip:

Gender:

Male

Female

Daytime Telephone Number: ( )

Mailing Address if different from above: PO Box, Street: City, State, Zip: E-mail Address: Preferred method for communication:

Suffix:

Mail

E-mail

PART 2—DECLARATION OF PRIMARY STATE OF RESIDENCE In accordance with the Nurse Licensure Compact “Primary State of Residence” is defined as the state of a person’s declared fixed, permanent and principal home for legal purposes; domicile. Documentation of primary state of residence requested may include: • • • • •

Driver’s license with a home address Voter registration card displaying a home address Federal income tax return declaring the primary state of residence Military Form No. 2058 – state of legal residence certificate W-2 from US Government or any bureau, division or agency thereof indicating the declared state of residence

Check all that apply: 1. My primary state of residence is Colorado. 2. I am in the process of moving or will be moving to Colorado and will claim Colorado as my primary state of residence. 3. I do not declare Colorado as my primary state of residency. My permanent residence is a state not participating in the nurse licensure compact. I understand my Colorado license will be valid in Colorado only as a Single State license. 4. I am declaring another compact state as my primary state of residence. Please put my Colorado license on expired status. 5. I am in the US Military (Active Duty) or with the US Federal Government and ___ a. practice exclusively in a federal or military system and request a Colorado single state license; or ___ b. also practice in a civilian health system (select 1 through 4 above). ATTESTATION: I state under penalty of perjury in the second degree, as defined in C.R.S. 18-8-503, that the information contained in this application is true and correct to the best of my knowledge. In accordance with C.R.S. 18-8- 501(2)(a)(I), false statements made herein are punishable by law and may constitute violation of the practice act.

Signature Declaration of Primary State of Residence

Date Page 1 of 1

8/2013