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May be cause for denial or loss of licensure and may result in criminal prosecution. Applicant's Signature Nurse Form 3, Page 1 of 2, Revised 5/17 Date Section II - Verification of Licensure/Certification (Please print or type) Instructions to the Licensing/Certifying Authority: Please complete items 1-4, sign and date the certification and return both pages of this form in an official envelope directly to the Office of the Professions at the address below. This form will not be accepted if r.

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