Follow the steps to successfully complete the NC DHHS DHSR/HCPEC 4502 form.

1. Click the 'Get Form' button to obtain the form and open it in the available online editor.
2. In the RN or LPN Information section, type or print your name as it appears on your nursing license. Ensure clarity to avoid any discrepancies.
3. Enter your maiden name and your mother’s maiden name in the respective fields, as these may be necessary for identification purposes.
4. Provide your full Social Security number. This information is used solely for identification and will be kept confidential.
5. Fill in your date of birth in the specified format (Month/Day/Year). Ensure this matches your identification documents.
6. Input your RN or LPN license number along with the state in which it was issued. This information validates your licensure.
7. Indicate your license type by selecting either RN or LPN, and if you are a new graduate, include the date of your graduation.
8. Provide your mailing address, including street or PO Box, city, state, and zip code for correspondence purposes.
9. List your contact information, including home phone, cell phone, work phone, and email address.
10. Answer the question regarding prior listings on the NC Nurse Aide I Registry by selecting 'Yes' or 'No' and include your NC Listing number if applicable.
11. Sign and date the application to authorize the verification of your nursing license. This step is essential for processing your application.
12. After all fields are completed, review the form for accuracy. Once verified, you can save changes, download, print, or share the completed form for submission.

Complete your application online today to ensure you are listed on the NC Nurse Aide I Registry.