Department Use Only
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
Verification of National Nurse Practitioner Examination
(Use this form ONLY if you are seeking a New York State certificate through a national certifying organization.)
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.
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
Social Security Number
Birth Date Month
(Leave this blank if you do not have a U.S. Social Security Number)
New York State Registered Professional Nurse License Number
Print Name as It Appears on Your Application for a Certificate (Form 1)
(You must notify the Department promptly of any address or name changes.)
National certifying organization: ___________________________________________________________________________________
Certification examination passed: Title: ____________________________________________ Date: ________ / ________ / ________
Are you currently certified?
If yes, certification number: ______________________________________________ Expiration date: ________ / ________ / ________
Print name under which certificate was awarded (if different from above).
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.
________ / ________ / ________
Nurse Practitioner Form 3, Page 1 of 2, (Rev. 3/09)