I am applying for licensure as a:

1. Licensed Practical Nurse
2. Registered Nurse

If you do not have a U.S. Social Security Number do not continue with this application, call (605) 362-2760.

1. First Name:
2. Middle Name:
3. Last Name:
4. Maiden Name:
5. Other Name:
6. Date of Birth: Please select January February March April May June July August September October November December / Please select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Please select 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
7. Social Security #:
   000-00-0000
8. Gender: Please select Female Male
9. Ethnicity: Please select American Indian or Alaska Native Asian Black / African American Hispanic / Latino Native Hawaiian or Other Pacific Islander White / Caucasian Other
10. U.S. Citizen: Please select N Y

1. Address Line 1:
2. Address Line 2:
3. City:
4. County: Please select Aurora Beadle Bennett Bon Homme Brookings Brown Brule Buffalo Butte Campbell Charles Mix Clark Clay Codington Corson Custer Davison Day Deuel Dewey Douglas Edmunds Fall River Faulk Grant Gregory Haakon Hamlin Hand Hanson Harding Hughes Hutchinson Hyde Jackson Jerauld Jones Kingsbury Lake Lawrence Lincoln Lyman Marshall McCook McPherson Meade Mellette Miner Minnehaha Moody Oglala Lakota Out of State Pennington Perkins Potter Roberts Sanborn Spink Stanley Sully Todd Tripp Turner Union Walworth Yankton Ziebach
   Choose Out of State if you do not live in SD.
5. State: Please select AK AL AR AZ CA CO CT DC DE FL GA GM GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY OT
6. Zip Code:
7. Home Phone:
   000-000-0000
8. Work Phone:
   000-000-0000
9. Cell Phone:
   000-000-0000
10. Email:
    account@domain.com