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Ed. RN Interim Executive Officer INDIVIDUAL CANDIDATE ROSTER DIRECTOR APPROVAL The following form must be completed and submitted to the Board for a candidate to be eligible for the NCLEX-RN and an interim permit prior to the Board receiving final official transcripts. 11/21/2012 Signature of Nursing Director Date SCHOOL SEAL Rev. 07-10 Attachment 4 NAME Last First Middle This portion OR a comparable form must be submitted if the candidate completed some nursing received from the school of graduation. This information can be submitted with the roster or transcript. BOARD OF REGISTERED NURSING P. O Box 944210 Sacramento CA 94244-2100 P 916 322-3350 www. rn*ca*gov Louise Bailey M. This form must be sent directly from the school of nursing NO SOONER THAN FOUR WEEKS PRIOR TO GRADUATION OR COMPLETION OF NURSING REQUIREMENTS* PRINT OR TYPE LAST NAME FIRST NAME DATE OF BIRTH mm/dd/yyyy MIDDLE NAME SOCIAL SECURITY NUMBER PREVIOUS NAMES INCLUDING MAIDEN NURSING PROGRAM California State University Long Beach THE FOLLOWING SECTION MUST BE COMPLETED BY THE NURSING PROGRAM DIRECTOR An individual candidate worksheet is available on the reverse side of this form I certify that the NCLEX-RN based on the X has completed educational requirements for Candidate s Name following status check only one Graduate completed all degree and nursing requirements 12/20/2012 Graduation date Month / Date / Year Already has a previous degree A. A. B. S* etc* and completed all nursing requirements Completion date of nursing requirements Previous degree Graduation Date Non-Graduate completed nursing requirements only LVN 30-Unit Option Licensed LVN has completed 30 semester units or 45 quarter units Entry Level Master s Program - Baccalaureate Degree in another field completed pre-licensure requirements I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. This form must be sent directly from the school of nursing NO SOONER THAN FOUR WEEKS PRIOR TO GRADUATION OR COMPLETION OF NURSING REQUIREMENTS* PRINT OR TYPE LAST NAME FIRST NAME DATE OF BIRTH mm/dd/yyyy MIDDLE NAME SOCIAL SECURITY NUMBER PREVIOUS NAMES INCLUDING MAIDEN NURSING PROGRAM California State University Long Beach THE FOLLOWING SECTION MUST BE COMPLETED BY THE NURSING PROGRAM DIRECTOR An individual candidate worksheet is available on the reverse side of this form I certify that the NCLEX-RN based on the X has completed educational requirements for Candidate s Name following status check only one Graduate completed all degree and nursing requirements 12/20/2012 Graduation date Month / Date / Year Already has a previous degree A. A. B. S* etc* and completed all nursing requirements Completion date of nursing requirements Previous degree Graduation Date Non-Graduate completed nursing requirements only LVN 30-Unit Option Licensed LVN has completed 30 semester units or 45 quarter units Entry Level Master s Program - Baccalaureate Degree in another field completed pre-licensure requirements I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

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