Nursing Licensure Form Completion Request

Complete this form if you have nursing licensure document(s) to be filled out by the university. Information will be sent directly to the requesting body.

Nursing students are not required to submit this form as part of their application for the CNO NCLEX exam.

A $102 non-refundable administrative fee will be placed on your account upon receipt of this request. It is your responsibility to pay this fee immediately. Please visit the following link for your payment options. If you do not pay this fee, a hold will be placed on your account and your request will not be sent to the requesting body.

The length of time for requests to be processed is normally 2-3 weeks. During peak periods, processing time may be longer.

Note: If you also require an official transcript, you must request it using the Request for Official Transcript of Academic Record form, as it is a separate request.

General Information
Current Name Current Name First Last
Name while attending Ontario Tech (if different from above) Name while attending Ontario Tech (if different from above) First Last
Student Number
Must be 9 digits. Currently Entered: 3 digits.
Ontario Tech Email Address

We will only send information to a registered Ontario Tech email account.
Phone Number
Date of Birth Date of Birth / MM / DD YYYY
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Program Specific Information
Program Attended
What year did you start the program?
What year did you graduate?
Upload all information/paperwork that is required to be completed by the Faculty of Health Sciences, Nursing team.

Please ensure that you have completed any information that is to be provided by the applicant.

Attach Files

Note: If you also require an official transcript, this is a separate request which you must complete online through MyOntarioTech.
Is an official transcript required to be sent with this documentation?
Request your transcript using the Request for Official Transcript of Academic Record form.
Acknowledgement

Acknowledgement
I understand that a $102 non-refundable administrative fee will be placed on my tuition account upon receipt of this request. This fee must be paid before the completed form(s) can be sent to the requesting body.

Please visit the following link for your payment options.
Disclaimer

Personal information on this form is collected under the authority of the University of Ontario Institute of Technology Act, SO 2002, c. 8, Sch. O. and will be collected, protected, used, disclosed and retained in compliance with Ontario’s Freedom of Information and Protection of Privacy Act R.S.O. 1990, c. F.31. This information will be used for education, administrative and statistical purposes and to administer registration within the University. Questions regarding the collection of your personal information may be directed to the Registrar, 2000 Simcoe Street North, Oshawa, ON L1G 0C5, 905.721.3190, email: connect@ontariotechu.ca.

If you require this information in an alternative format due to disability, please email records@ontariotechu.ca.

Nursing Licensure Form Completion Request

Nursing Licensure Form Completion Request

General Information

Program Specific Information

Request your transcript using the Request for Official Transcript of Academic Record form.

Disclaimer