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APPLICATION FOR NCLEX®® FOR IMMIGRATION PURPOSES

As of January 1, 2005, the information below applies to Canadian nurses licensed in Maine. (We are no longer making applicants licensed outside of Maine eligible to write the NCLEX® exam for
VISA certification purposes.)


APPLICATION FOR NCLEX®® FOR IMMIGRATION PURPOSES

Name________________________________________________________

List any other names used previously_________________________________

ResidentialAddress______________________________________________

_____________________________________________________________

MailingAddress_________________________________________________

U.S. Social Security Number_______________________________________
(A U.S. SSN is required for licensure in Maine but not required to take NCLEX®®)

Maine Nursing License Number____________________________________

Other U.S. Nursing Licenses and Numbers: State & Number______________
Other Countries and License Number, if any___________________________

Purpose for which you are requesting to sit for NCLEX®®:

______________Immigration ______________Other (Please explain)

Is this the first time you are taking NCLEX®® ______YES _____NO

Telephone number at which you can be reached:(___)____________________

Signature of Applicant:__________________________________________

Notary:_____________________________________________________

Date:_______________________________________________________