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TEXAS BOARD OF NURSING 333 GUADALUPE 3-460 AUSTIN TEXAS 78701-3944 512 305-7400 - 512 305-7401 FAX SWORN DECLARATION OF PRIMARY STATE OF RESIDENCE NAME ADDRESS CITY STATE ZIP RN/LVN LICENSE SSN DATE OF BIRTH E-Mail Address Yes No Business Fax Number Are you currently employed in the U.S. Military Active Duty or the U.S. Federal Government In accordance with the Nurse Practice Act Texas Occupations Code Chapter 304. 001 Nurse Licensure Compact and 22 TAC 220. 2 I declare the State of as my primary state of residence and that such constitutes my permanent and principal home for legal purposes. Primary state of residence is defined as the state of a person s declared fixed permanent and principal home for legal purposes domicile. I intend to practice in the state s of List up to 10 states e*g* Texas Arkansas Maryland New Mexico etc* Signature Date Revised 10/2007. 001 Nurse Licensure Compact and 22 TAC 220. 2 I declare the State of as my primary state of residence and that such constitutes my permanent and principal home for legal purposes. Primary state of residence is defined as the state of a person s declared fixed permanent and principal home for legal purposes domicile. Primary state of residence is defined as the state of a person s declared fixed permanent and principal home for legal purposes domicile. I intend to practice in the state s of List up to 10 states e*g* Texas Arkansas Maryland New Mexico etc* Signature Date Revised 10/2007. 001 Nurse Licensure Compact and 22 TAC 220. 2 I declare the State of as my primary state of residence and that such constitutes my permanent and principal home for legal purposes. Primary state of residence is defined as the state of a person s declared fixed permanent and principal home for legal purposes domicile. I intend to practice in the state s of List up to 10 states e*g* Texas Arkansas Maryland New Mexico etc* Signature Date Revised 10/2007.

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