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NON-REFUNDABLE FEE 25. 00 MISSISSIPPI BOARD OF NURSING 713 Pear Orchard Road Suite 300 Ridgeland MS 39157 601 957-6300 AFFIDAVIT FOR NAME CHANGE Enter name below as associated with your nursing license. NAME First Middle Maiden Last Enter requested name change below to be associated with your nursing license. Enter data below as indicated. SOCIAL SECURITY ADDRESS PO BOX/STREET LICENSE CITY STATE ZIP CODE COUNTY My primary state of residence is NA.

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