Maryland Board of Nursing

"*" indicates required fields

Is this form for a new application or a renewal application?*

New

Renewal

This field is hidden when viewing the form

ORI Code for New

This field is hidden when viewing the form

ORI Code for Renewal

This field is hidden when viewing the form

Authorization Code New

This field is hidden when viewing the form

Authorization Code Renewal

Name*

First Middle Last Suffix

Date of Birth*

Sex*

Race*

Height*

You must enter 2 digits for inches, ex: 5'03 for 5 foot 3 inches.

Weight*

Please enter a number greater than or equal to 1.

Eye Color*

Hair Color*

Were you born in the United States?*

Yes

Place of Birth

Country of Birth

Country of Citizenship*

Address*

Street Address City State ZIP Code

Phone*

Email*

Enter Email Confirm Email

Maryland Board of Nursing*

Price:

Total

Please choose an appointment time:*

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address*

Same as previous

Street Address City State ZIP Code

This field is hidden when viewing the form

CJIS Number