Application for Registered Nurse (RN) – In-Home Care

uKinnect, LLC

Statement of No History of Misconduct

Full Name:

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I affirm that I am a licensed Registered Nurse in good standing in the State of Georgia, and that I have no known history of professional misconduct, disciplinary action, or investigation by any licensing board, employer, or regulatory agency.

By signing below, I declare that the information provided is true and accurate to the best of my knowledge.

Signature:

signature

Date:

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Printed Name:

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License Number:

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