Contact for Retired Status Application

Complete this form to request an application for Retired License Status.

First Name:
Last Name:
Mailing Address
Street:
Address Line 2:
City:
State:
Zip:
Phone:
Email:
Subject:
Comments:
Are you licensed as a nurse in Kentucky?	Yes No
If yes, please enter your RN/LPN License#:

Last Updated 8/13/2008