Directions for Completing the NCLEX® Examination Registration Form

Directions for Completing the NCLEX® Examination Registration Form


The registration scan form that is in the envelope enclosed with this Candidate Bulletin includes all of the questions that you must answer if you register via the internet, by mail or by telephone. If you submit your registration form by mail, your
registration form will be read by a computer and must be completed accurately to ensure timely and efficient processing.

You will be sent a confirmation indicating that your registration was received. Incomplete forms and forms received without the correct fee will be returned.

Page 1 of the Registration Form

For any of the three registration methods (internet, mail or
telephone) you will be asked to supply the following information.

Examination Fee

Please enter the number of your check or money order in the
boxes provided.

1. Examination for Which You Are Registering
Fill in the circle next to the NCLEX examination for which
you are registering, either Practical Nurse (NCLEX-PN® examination)
or Registered Nurse (NCLEX-RN® examination).

Once the registration has been submitted, candidates who want to change the type of examination requested or the board of nursing where licensure was requested must contact NCLEX Candidate Services and will be required to pay a $50 change fee.
Once a board of nursing declares you eligible to test, neither the board of nursing where licensure was requested nor the type of examination can be changed.

Your Name
2. Name
Enter your name exactly as it is printed on the picture identification that you will present at the test center.Do not change the spelling and do not change the order of
your names.

Print your last (family) name, first name, and your middle name in the spaces provided and completely fill in the corresponding circles. Print one letter clearly in each box. Leave blank spaces between each part of your name. If any of your
names are too long to fit in the boxes provided, print as much as will fit. If you have had a name change, and have been made eligible by your board of nursing, you must submit the name change to your board of nursing and request a new ATT
from the NCLEX Call Center. Do not call or write NCLEX Candidate Services with this information.

NOTE: The name on the ATT must match the name on
the identification you will present at the test center.

In the manual the sample entry is given in page 5 entry on an NCLEX
registration form.

Page 2 of the Registration Form

3. Mother’s Maiden Name
Print your mother’s maiden name and fill in the corresponding circles. Maiden name is the last (family) name your mother used at birth before marriage. Only the last name is needed,not the full name. Your registration will not be processed without this information. If you have questions please contact NCLEX Candidate Services at one of the numbers located on the inside front cover of this bulletin.

4. Your Date of Birth


Fill in the circle next to the month in which you were born.
Print the day and year in which you were born and completely
fill in the corresponding circles. For birth dates that are less
than 10, enter zero in the first “day” box (for example, if you
were born on April 2, 1966, you would fill in the circle next to
“April” and then enter 02 for the day and 1966 for the year).
Incomplete birth dates will delay processing.

5. U.S. Social Security Number
Print your United States Social Security number, if you have
one, and fill in the corresponding circles. This information is
optional but may be used by the board of nursing to link your
NCLEX® examination results to your application for licensure.
6. Ethnic Information
Indicate the appropriate ethnic information by filling in the
corresponding circle. This information is used for statistical
purposes only.
7. Sex
Indicate your sex by filling in the corresponding circle.
This information is used for statistical purposes only.
8. Telephone Number (Home/Mobile)
Print your home/mobile telephone number and fill in the
corresponding circles. This number will be used if it is
necessary to contact you about your registration.
9. Telephone Number (Work)
Print your work telephone number and fill in the
corresponding circles. This number will be used if it is
necessary to contact you about your registration.
10. E-Mail Address
If you have an e-mail address, print it in this space only if you
wish to receive all of your subsequent correspondence (confirmation
of registration, ATT and confirmation of examination
appointment) from Pearson VUE by e-mail ONLY. If you do
not provide an e-mail address, your correspondence from
Pearson VUE will arrive ONLY through U.S. mail.

Page 3 of the Registration Form
11. Your Maiden Name
Print your maiden name and fill in the corresponding circles.
Maiden name is the family name given to you at birth before
marriage.

12. Another Last Name You Have Used
Print any other last name you have used when registering for
the NCLEX examination or applying for licensure to a board
of nursing. Fill in the corresponding circles. The name you
enter must be the name you used immediately prior to the
name you currently use.
13. Last Date Other Name Was Used
Fill in the circle next to the month, and print and completely
fill in the corresponding circles of the year for the last date
that you used the name entered in number 12.
14. Primary Language
Fill in the circle next to the option that best describes your
language proficiency. This information is used for statistical
purposes only.
15. Education Program Code
Using the list of Education Program Codes beginning on page
20, enter the five-digit code of the program from which you
received your nursing education and fill in the corresponding
circles. If educated outside the U.S.*, use the international
education codes on page 41.


20a. U.S. Zip Code

If you live in the United States or its territories,
print your U.S. zip code and completely fill in the
corresponding circles.

20b. Country Code
Only if your mailing address is outside the United States and
its territories, use the International Country Code list on
page 19 to complete this item. Print the three-digit country
c ode and completely fill in the corresponding circles. There
is no country code for U.S. addresses.

20c. Foreign Postal Code
If you live outside the U.S., please print your international
postal code in this space. All testing at Pearson Professional
Centers is subject to U.S. government trade regulations and
restrictions regarding embargoed countries, some of which
are applicable to the provision of testing services in the U.S.
and its territories. You must supply an international postal
code when providing your address and make sure that such
reference is consistent with the address on your identification
that you present at the testing center.

Signature
Sign (do not print) in pencil or ink your full name and fill in the
date. Before you mail your registration form and examination
fee in the enclosed envelope, make sure that you have signed
your form and checked it for accuracy. Be sure that the proper
circles are filled in, that there are no stray marks and that your
form is complete and accurate.