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Have there ever been any formal sanctions imposed against the applicant as a matter of public record If yes attach a certified copy of disciplinary action. Yes No Signature of Registrar Print Name Date Please affix seal. Please return the completed form directly to Professional Licensing and Regulatory Affairs Attn. Licensing Officer P. Name of Applicant School of Nursing/Address Registration Status Active Inactive Other please specify Full Limited Practice Interim/Temporary Other...
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