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N, WI 53708-8935 (608) 261-7083 (608) 266-2112 BOARD OF NURSING APPLICATION FOR CERTIFICATION AS AN ADVANCED PRACTICE NURSE PRESCRIBER Under Wisconsin law, the Department must deny your application if you are liable for delinquent state taxes or child support (sec. 440.12, Stats.). Your name and address are available to the public. PLEASE TYPE OR PRINT IN INK Check box to withhold street address/PO Box number from lists of 10 or more credential holders (Wis. Stat. 440.14 Last Name Fir.

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