NEW MEXICO BOARD OF NURSING
ATTESTATION OF EXPIRED/LAPSED LICENSE/CERTIFCIATE
On this _________ day of _______________, 20______, I ___________________________, born on
(Print Name)
________________, swear and affirm as follows:
1.That I allowed my New Mexico License/Certification to expire/lapse. The reason for allowing this to occur is as follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Attach additional documents if necessary.
2.Please answer either question A or B below:
a.I attest that I did NOT work any hours/shifts in the State of New Mexico or another compact State, since the date in which my license expired/lapsed: ___________.
(Initial)
OR
b.I attest that I DID work on an expired/lapsed license. __________.
(Initial)
i.Supervisors Name: _____________________________
ii. Supervisors Telephone: ( |
) ___________________ |
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iii.Supervisors email Address: _____________________________
iv.Number of days/shifts worked in the State of New Mexico since the date in which my license expired/lapsed: __________________________
v.I have attached a list or payroll records of all dates and hours worked at a job related to my license/certificate from this day going back to the date when my license/certificate expired. ___________. (This also needs to be signed by your
supervisor).(Initial)
3.I understand this attestation as well as any supporting documents need be returned to the NMBON no later than 5 business days following the date of submission of my renewal application. Failure to provide this attestation within the time period required could result in disciplinary action taken towards my New Mexico licensure/certificate ___________.
(Initial)
I swear or affirm that the above and foregoing representations are true and correct to the best of My information, knowledge, and belief.
____________________ |
__________________________ |
______________ |
Print Name |
Signature |
Date |
Any misrepresentation on this attestation can lead to disciplinary action and will be forwarded to the Compliance Division for investigation.
