"Third-Party Authorization Form" - Nevada

Third-Party Authorization Form is a legal document that was released by the Nevada State Board of Nursing - a government authority operating within Nevada.

Form Details:

  • Released on March 30, 2016;
  • The latest edition currently provided by the Nevada State Board of Nursing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Nevada State Board of Nursing.

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N
Nevada State Board of
URSING
Third-Party Authorization
If you would like someone other than yourself to act as your representative in the
licensure process for this application, please complete this form and have your signature
notarized. Discard this form if you are submitting the application for yourself and do not
want another person to act on your behalf.
I,
, the undersigned, do hereby
authorize
, whose address is
,
his/her agents or employees, to act for me and in my name with respect to my application
for licensure with the Nevada State Board of Nursing, as follows:
Act as my representative on all matters with the Board of Nursing.
This authorization ends on the date my permanent license/certificate is issued.
Date
Signature
State of
County of
This instrument was acknowledged before me on
/
/
by
SEAL
Notary Public
5011 Meadowood Mall Way, Suite 300, Reno, NV 89502-6576 (fax) 775-687-7707
4220 S. Maryland Pkwy., Suite 300, Las Vegas, NV 89119-7533 (fax) 702-486-5803
www.nevadanursingboard.org  888-590-6726  nursingboard@nsbn.state.nv.us
rev. 03-30-16
N
Nevada State Board of
URSING
Third-Party Authorization
If you would like someone other than yourself to act as your representative in the
licensure process for this application, please complete this form and have your signature
notarized. Discard this form if you are submitting the application for yourself and do not
want another person to act on your behalf.
I,
, the undersigned, do hereby
authorize
, whose address is
,
his/her agents or employees, to act for me and in my name with respect to my application
for licensure with the Nevada State Board of Nursing, as follows:
Act as my representative on all matters with the Board of Nursing.
This authorization ends on the date my permanent license/certificate is issued.
Date
Signature
State of
County of
This instrument was acknowledged before me on
/
/
by
SEAL
Notary Public
5011 Meadowood Mall Way, Suite 300, Reno, NV 89502-6576 (fax) 775-687-7707
4220 S. Maryland Pkwy., Suite 300, Las Vegas, NV 89119-7533 (fax) 702-486-5803
www.nevadanursingboard.org  888-590-6726  nursingboard@nsbn.state.nv.us
rev. 03-30-16