RES Nursing License Confirmation Form (Form 102) : E R E S
RES Nursing License Confirmation Form (Form 102) : E R E S
8. Current status of nursing license: active, inactive, expired (Date expired: MO / DAY / YEAR), disciplinary action
Please explain circumstances of disciplinary action: _______________________________________________________
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9. On what basis was the license issued to the applicant? 1 Completion of nursing education program, 1 Transfer from
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11. Name/Title of person confirming this information: ________________________________________________________
ERES: 2480 Hilborn Rd, Ste 106, Fairfield, CA 94534, U.S.A. w 707-759-2866 w [email protected] w www.eres.com