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        California  Nurses' Registry Bond Application

 
 

Nurses' Registries         Secure Web Application

Every nurses' registry subject to this title shall maintain a bond issued by a surety company admitted to do business in this state. The principal sum of the bond shall be three thousand dollars ($3,000). A copy of the bond shall be filed with the Secretary of State.


$3000 Bond    
 (Issued on Receipt of Application, no qualifications)
A credit card is required for on line processing and a 6% service fee will be charged
Use the print / mail form and send with your check to avoid a fee

Please note: All surety bonds require manual execution (Original Signature and Seal).

Term / Premium  -    2 yrs / $175.00   

Applicant - Name that will appear on Bond

        Social Sec. #

                    Age                   Married Single    

Address: 

Street      City, State 

                         Zip        Telephone

Effective Date: 
Email Address  
Comments

Payment: 
Credit Card Payment Required with this form
(A 6% on line processing fee will be added) 

All Credit Cards are Manually Processed at the time the Bond is Issued.

VISA or Master Card Account Number     
 3 Digit Security  Code 
Expiration Date  

Name as Shown on Credit Card  
                    

Credit Card Billing Address:   Same As Above 
  (If different from above)                            
                             

                             

Please Enter "app10" below

 

IF YOU ALREADY HAVE THIS BOND WITH US, PLEASE USE THE ON LINE RENEWAL FORM


For Appointed Brokers*
Broker Code 
Broker Name
*need filled in to receive commission

  
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