LPN IV Therapy Approval Application Name of Applicant Nursing License # Street Address City State Zip Code Telephone # Email Address Name of Provider Provider Street Address City State Zip Code Title of Course Date Course was Completed Was the course taken within your LPN Curriculum? Please select Yes/No YesNo List the number of successful peripheral venous access procedures required within the course. Attestation I realize that this application is a legal document and by pressing the Submit button I am declaring under penalty of perjury under the laws of the State of Kansas that the information I have provided is true and correct to the best of my knowledge. If all the above information is correct please press the Submit button . Otherwise please go back and correct any information that is necessary. SUBMIT WILL CONTINUE YOU ON TO THE FILE UPLOAD PAGE
