• Nurse Practitioner Client Intake Form

    Thank you for choosing National Med Licensing. We specialize in helping Nurse Practitioners obtain, renew, and expand professional licensure across the United States. Please select the service that best fits your needs below. Most clients complete this intake form in approximately 10–15 minutes.

  • Service Options & Pricing

    How would you like National Med Licensing to assist you?

  • 30-Minute Licensing Strategy Session — $100

    Receive personalized guidance on state licensing requirements, multi-state licensing strategies, the Nurse Licensure Compact, application planning, and answers to your licensing questions. This service does not include application preparation or management.

    Full-Service Licensing Support — Starting at $350 Per State

    We prepare and manage your licensing application from start to finish, including application preparation, state-specific requirement review, document coordination, application tracking, and follow-up support. Multi-state package pricing is available.

     

  • Please select the service you'd like to receive.*

  • Consultation Information

    Please answer the questions below so we can prepare for your licensing strategy session.
  • Format: (000) 000-0000.
  • What would you like to discuss during your consultation? (Select all that apply.)

  • Personal Information

  • Have you ever used any other name, including a maiden name, previous married name, alias, or different spelling of your name?*
  • What is your DOB?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is your mailing address different from your residential address?*
  • Format: (000) 000-0000.
  • Are you Hispanic or Latino?

  • Nursing & Advanced Practice Education

  • Please provide your nursing education information exactly as it appears on your academic records. This information is used to complete state RN and advanced practice licensing applications. Some state licensing boards may require official transcripts to be sent directly from the educational institution.

  • Initial Nursing Education

  • Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Graduation Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Nursing Practitioner Qualifying Education

  • Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Graduation Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you completed an additional NP/APRN specialty program or post-master's certificate?*
  • Have you completed any additional college, graduate, post-graduate, or doctoral education not already listed above?*
  • Additional Higher Education

  • Licensure & Certification

  • Original Certification Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Certification Expiration Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you currently hold a Multistate Compact RN License?*
  • List every RN/APRN/PMHNP license you have ever held, including expired or inactive licenses
  • Do you currently have a DEA Registration?*
  • Expiration Date of Your DEA Registration:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Licensing Goals

  • Do you want prescriptive authority included with your APRN/NP application where applicable?
  • When do you need your license(s)?

  • Supporting Documents

    Please upload the documents you currently have available. Certain items are required to begin full-service licensing. Official transcripts or verifications that must be sent directly by another organization will be coordinated separately.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Background Questions

  • Has any professional license, certification, registration, or application ever been denied, disciplined, restricted, suspended, revoked, surrendered, reprimanded, fined, placed on probation, or otherwise acted upon?*
  • Have you ever had a DEA registration denied, suspended, or revoked?*
  • Are you currently the subject of a pending professional licensing investigation or Board complaint?*
  • Have your hospital or clinical privileges ever been restricted, suspended, terminated, revoked, or voluntarily surrendered while under investigation?*
  • Have you ever been arrested, charged with, convicted of, or entered a plea of guilty or no contest to a criminal offense that may require disclosure on a professional licensing application?*

  • Final Review and Authorization

  • Licensing Fee Payment Preference

  • How would you like to handle required licensing and application fees?*

  • State licensing, Board of Nursing, DEA, fingerprinting, background check, verification, and other third-party application fees are separate from National Med Licensing service fees and are the client's responsibility.

  • Licensing Portal Account Management

  • Licensing Portal Email Preference*

  • Applicant Participation & Final Submission

    Some state licensing boards require applicants to personally access the licensing portal to review an application, enter or verify sensitive information, complete attestations or electronic signatures, and/or submit the application. National Med Licensing will notify you when your participation is required.

  • Authorization & Consent*

  • Privacy & Information Authorization

    By submitting this form, you authorize National Med Licensing to collect, use, and submit the personal, educational, professional, and licensing information you provide for the purpose of assisting with professional licensing and credentialing services.

    Your information may be shared with applicable state licensing boards, regulatory agencies, certification organizations, educational institutions, and other entities as reasonably necessary to complete or support your requested licensing services.

    National Med Licensing will take reasonable measures to protect your information and will not disclose your information to unauthorized third parties except as required by law or as necessary to provide the services you have requested.

    You may revoke this authorization in writing at any time; however, revocation will not affect actions already taken based on your prior authorization.

  • ⚠️ IMPORTANT: One final step!
    After you click Submit, a pop-up will appear. Please review your information and click "Sign Document." Do not close the pop-up—your submission is not complete until you click "Sign Document."

  • Should be Empty: