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That I CANNOT PRACTICE NURSING while maintaining a retired nurse license; and that I have read and understand this application. I understanding that if the processing of this application is not completed, the application becomes null and void one year from date received and that all fees are non-refundable. I also understand that falsification of this form is grounds for disciplinary action against my license. APPLICANT S SIGNATURE FOR OFFICE USE ONLY AR CERT. NO. DATE DATE 3.10 lw 01-0022.

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