Nurse Practitioner Form 3 - Verification Of National Nurse Practitioner Examination
ADVERTISEMENT
1
2Department Use Only
The University of the State of New York
Nurse Practitioner
THE STATE EDUCATION DEPARTMENT
Approved
Office of the Professions
Form 3
Division of Professional Licensing Services
Date
Verification of National Nurse Practitioner Examination
(Use this form ONLY if you are seeking a New York State certificate through a national certifying organization.)
Applicant Instructions
1.
Complete Section I. In item 4, enter your name exactly as it appears on your Application for a Certificate (Form 1). Be sure to sign and
date item 9.
2.
Send the entire form to the national certifying organization. Ask them to complete Section II and forward both pages of the form directly
to the Office of the Professions at the address at the end of this form. Be sure to include any fee required. This form will not be
accepted if submitted by the applicant or any other party.
Section I: Applicant Information
1
2
1.
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
3.
New York State Registered Professional Nurse License Number
4
3.
Print Name as It Appears on Your Application for a Certificate (Form 1)
Last
First
Middle
5
4.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
6.
National certifying organization: ___________________________________________________________________________________
Certification examination passed: Title: ____________________________________________ Date: ________ / ________ / ________
mo.
day
yr.
7
7.
Are you currently certified?
Yes
No
If yes, certification number: ______________________________________________ Expiration date: ________ / ________ / ________
mo.
day
yr.
8
8
Print name under which certificate was awarded (if different from above).
Name: _______________________________________________________________________________________________________
9
9.
I request and give my permission to the national certifying organization listed in item 6 above to complete Section II of this form and
mail it to the New York State Education Department at the address at the end of this form, and to release any other information
requested by the State Education Department in connection with my application for a certificate.
_______________________________________________________________________________
________ / ________ / ________
Applicant’s Signature
mo.
day
yr.
Nurse Practitioner Form 3, Page 1 of 2, (Rev. 3/09)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Clinical Nurse Specialist Form 3c - Verification Of National Clinical Nurse Specialist Certification
Legal
Clinical Nurse Specialist Form 3 - Verification Of Other Professional Licensure/certification - 2014
Legal
Related Categories
Parent category: Legal