• 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 full-service licensing applications take approximately 10 minutes to complete.

  • 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

  • What is your DOB?*
     - -
  • Format: (000) 000-0000.

  • Nursing 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.

  • Bachelor's Nursing Education

  • Undergrad Nursing School - Start Date*
     - -
  • Undergrad Nursing School - Graduation Date*
     - -

  • Graduate/Advanced Practice Nursing Education

  • Graduate Nursing School - Start Date*
     - -
  • Graduate Nursing School - Graduation Date*
     - -

  • Licensure & Certification

  • What is the Certification Expiration Date?*
     - -
  • Expiration Date of your Primary RN License:*
     - -
  • Do you currently hold a Multistate Compact RN License?*
  • Expiration Date of your Primary APRN License:*
     - -
  • Do you currently have a DEA Registration?*
  • Expiration Date of Your DEA Registration:
     - -

  • Licensing Goals

  • When do you need your license(s)?

  • Supporting Documents (Optional)

    Uploading these documents may speed up your licensing process, but they are not required at this stage.
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  • Background Questions

  • Have you ever had disciplinary action against a nursing license?*
  • Have you ever been denied a nursing license?*
  • Have you ever had a DEA registration denied, suspended, or revoked?*
  • Have you ever been convicted of a misdemeanor or felony?*
  • Have you ever practiced under another legal name?*

  • 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."

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