As of January 1, 2005, the information below applies to
Canadian nurses licensed in Maine. (We are no longer making
applicants licensed outside of Maine eligible to write the NCLEX
exam for
VISA certification purposes.)
APPLICATION FOR NCLEX® FOR IMMIGRATION PURPOSES
Name________________________________________________________
List any other names used previously_________________________________
ResidentialAddress______________________________________________
_____________________________________________________________
MailingAddress_________________________________________________
U.S. Social Security Number_______________________________________
(A U.S. SSN is required for licensure in Maine but not required
to take NCLEX®)
Maine Nursing License Number____________________________________
Other U.S. Nursing Licenses and Numbers: State & Number______________
Other Countries and License Number, if any___________________________
Purpose for which you are requesting to sit for NCLEX®:
______________Immigration ______________Other (Please explain)
Is this the first time you are taking NCLEX® ______YES
_____NO
Telephone number at which you can be reached:(___)____________________
Signature of Applicant:__________________________________________
Notary:_____________________________________________________
Date:_______________________________________________________
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