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-2100 P (916) 322-3350 F (916) 574-8637 www.rn.ca.gov Louise R. Bailey, MEd, RN, Executive Officer License Renewal - Timely Office Use Only Fee - $140 ALLOW 6-8 WEEKS FOR PROCESSING YOUR RENEWAL BY MAIL Mail this completed form along with the appropriate fee to the address above License No: Date License Expires: Amt Recd: CE s OK: Active / Inactive Total Amount Due: $ 140 Full Name: Last 4 Digits of Your SSN or ITIN: Date of Birth: Mailing Address: City, State, Zip Phone Number: Em.

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