How to Complete the Georgia Board of Nursing Employment Verification Form

The Georgia Board of Nursing employment verification form documents your nursing work history so the Board can confirm your practice hours for licensure by endorsement or reinstatement. You complete Section I with your contact information, your employer completes Section II with your job title, employment dates, and hours worked, and a notary witnesses the employer’s signature. The finished form goes to nursing@sos.ga.gov or into your GOALS portal application.

When You Need the Form

Two situations trigger this form: applying for a Georgia license by endorsement from another state, and reinstating a lapsed Georgia license.

For endorsement, the employer name and address on the verification form must match what you listed under “Employment History” on your application.¹

For reinstatement, the form is how you prove at least 500 hours of licensed nursing practice within the four years before applying. The same 500-hour threshold applies to both RNs and LPNs.²³

One boundary worth flagging: this is not the form used at biennial renewal. If you are satisfying continuing competency through employer-verified practice hours under O.C.G.A. § 43-26-9, that uses a separate employer certification included in the Board’s continuing education packet, not this standalone document.⁴

Download the current form directly from the Secretary of State site. The RN version and the APRN version are separate documents, so pick the one that matches your license type.⁵⁶

Section I: Your Information

Fill in your last name, first name, physical address, city, state, zip code, phone number, and email. Sign and date the bottom of Section I. The form does not ask for your license number or Social Security number. If those fields appear on the document in front of you, you are probably looking at a different form, such as the criminal background consent that accompanies endorsement applications.

Hand the form to your employer once Section I is done. Do not sign anywhere else on the document.

Section II: What Your Employer Fills In

Your employer completes the rest of the form. The first block captures the facility’s legal business name, physical address, phone number, and email.

Next comes a short set of yes-or-no questions about the type of facility:

Whether the facility is a federal government agency
Whether it is an acute care inpatient hospital
Whether it is a long-term acute care (LTAC) facility
Whether it is an ambulatory surgical or obstetrical facility under O.C.G.A. § 31-6-2
Whether it is a skilled nursing facility with at least 100 beds serving patients with needs similar to LTAC patients

Below those questions, the employer writes your position or job title and indicates whether an RN or APRN license is required for the role. If you practiced at a physical site different from the employer’s main office, a second address block captures that location.

The employment dates section records the month and year you started and the month and year you left, or “present” if you are still there. Extended absences, such as parental or medical leave that interrupted active practice, are noted separately.

Hours worked go into a grid, broken out by year, with a corresponding job title or description on each row. For reinstatement applicants this grid is what the Board measures against the 500-hour requirement, so the numbers should reflect actual practice hours rather than scheduled hours or a lump estimate.²

Notarization

The person completing Section II prints their name and title, then signs. A notary public witnesses that signature and adds their own signature, stamp, and commission expiration date.⁷

If no notary is available at your facility, the amended version of the form allows the employer to submit a letter on company letterhead stating that no notary is on site, sent along with the completed form. Leaving the notary block empty without that letter is a common reason forms come back.

How to Submit the Completed Form

The most direct route is email. Send a scanned copy of the notarized form to nursing@sos.ga.gov.⁷ The APRN form also lists a fax option at 877-371-5712.⁶

If you are filing endorsement through the GOALS online portal, upload the scanned form with the rest of your application documents.⁸ Your employer can also seal the notarized form in an envelope for you to include in the packet.¹

The Board’s current mailing address is 3920 Arkwright Rd, Suite 195, Macon, GA 31210.⁹ Older references list a former address on Coliseum Drive; do not use it. The Board has stated it no longer accepts paper applications,¹⁰ so email or portal upload is the safer route for supporting documents too.

Processing Time and Deficiency Notices

The Board typically reviews applications within fifteen business days after receiving all required documents. A criminal history flag, prior discipline, or missing paperwork can extend that timeline while staff review the issue.¹¹

If something is incomplete, a deficiency notice appears in your GOALS portal. You have 60 days to upload the missing documents through the portal’s amendment process.¹² Applications not completed within the timeframe set by the Joint Secretary’s rules are withdrawn, and you would have to file a new application and pay the fee again.² Check the portal directly rather than waiting on email; status updates post there first.

Mistakes That Get the Form Rejected

Missing notarization with no letterhead letter explaining the absence.
Employer name or address on the form not matching your application’s employment history.
Hours entered as a lump total or scheduled hours instead of actual practice hours broken out by year, with no notation of extended absences.
Using the RN form for an APRN applicant, or a stale version pulled from a third-party site rather than the Secretary of State’s page.
Mailing to the old Coliseum Drive address instead of the Arkwright Road office.

1
Georgia Secretary of State. RN Licensure by Endorsement Application
2
Georgia Rules and Regulations. Georgia Comp R and Regs R 410-4-.01 – Licensure by Reinstatement (RN)
3
Georgia Secretary of State. Chapter 410-4 Licensure by Reinstatement
4
Georgia Secretary of State. Georgia Board of Nursing Continuing Education Packet
5
Georgia Secretary of State. RN Verification of Employment
6
Georgia Secretary of State. Georgia Board of Nursing – APRN Verification of Employment
7
Georgia Secretary of State. Georgia Board of Nursing – Verification of Employment Form
8
Georgia Secretary of State. How to Guide – Registered Nurse
9
Georgia Secretary of State. About the Licensing Division
10
Georgia Secretary of State. Georgia Board of Nursing
11
Georgia Secretary of State. FAQs for Nursing
12
Georgia Secretary of State. GOALS