|License #||Soc. Sec. #|
STATE OF _________________________
COUNTY OF ________________________
I, the undersigned, being duly sworn according to law, do depose and say that on or about the day of __________________ , 20___ , I lost my original West Virginia Certificate of Registration (license card), Number __________________ , entitling me to practice as a registered professional nurse in West Virginia, and that this affidavit is necessary in order that a record of this loss may be filed in the offices of the West Virginia State Board of Examiners for Registered Nurses, and that a replacement may be issued to me. The said certificate was lost or stolen or never received by me in, on, or about the following time and location and under the following circumstances:
Signature of Affiant ________________________________
Subscribed and sworn to before me this ________________ day of __________________ , 20___.
My commission expires on the ________________ day of __________________ , 20___.
Notary Public in and for