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COMMONWEALTH BOARD OF NURSE EXAMINERS

NORTHERN MARIANA ISLANDS


P.O. Box 501458, Saipan, MP 96950
Telephone: (670) 664-4810
Email: cbone@pticom.com
Verification of License for RNs and LPNs

1. Complete your name and mailing address in areas marked and forward the form to the State Board where currently licensed.
2. In addition to filing the original of this form, please submit:
a) Appropriate fee.

Print or Type Name (Last) (First) (Middle)


FLORESCA FRITZ IAN ESTRELLA
Other Name(s) Used: Social Security Number:
n/a n/a
Current Address of Record: Date of Birth:
B4-L3 San Antonio De Padua 1, Dasmarinas city
Cavite, Philippines 4114 MARCH 26, 1988
State of Current Licensure: Issue Date: Current License Number:
SAIPAN – NMI FEBRUARY 4, 2019 R190236
State of Original Licensure: Issue Date: Original License Number:
SAIPAN – NMI FEBRUARY 4, 2019 R190236
I hereby authorize all identified Boards of Nursing to release my licensure date to the Commonwealth Board of Nurse Examiners.
May 9, 2019
Signature:__________________________________________________________________
Date:___________________________________________

The above applicant has applied for license to practice nursing in the Commonwealth of the Northern Mariana Islands. Please supply the following information
and return this form directly to:

Commonwealth Board of Nurse Examiners


Northern Mariana Islands
P. O. Box 501458
Saipan, MP 96950

To be completed by licensing board and sent to Commonwealth Board of Nurse Examiners listed above.
License Number: Issue Date: Expiration Date: How issued?

Waiver Endorsement Examination


Current licensure status: Active Inactive Lapsed

Name of Professional Nursing Program: Approved by State: Graduated from:


Yes No High School HS Equivalent/GED
Location: Graduation Date: Type of Nursing Program:
AD DIP BSN MSN Other
Examination Passed:

 NCLEX  SBTPE  Other, please specify. Taken in English?  Yes  No


Scores: SBTPE
Exam Series or Date:
NCLEX ____ Medical _____ Surgical _____ Obstetric _____ Pediatric _____ Psychiatric_____
Ever suspended or revoked? (If yes, please explain and include the type of discipline and date.)

Has license ever been reinstated? ______ Yes ______ No


Signature: ____________________________________________ Title: ________________________________

Board of Nursing:______________________________________ Date: _________________________________


(Board Seal)
CBNE – Doc 29