Nurse Practitioner Form 3 - Verification Of National Nurse Practitioner Examination Page 2
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2Section II: Verification of National Nurse Practitioner Examination
Instructions to National Certifying Organization: Please complete Section II and return both pages of this form directly to the New York
State Education Department at the address at the end of this form. This form will not be accepted if returned by the applicant or any
other party.
1.
It is hereby verified that: __________________________________________________________________________________________
(Section I, item 8)
has passed the nurse practitioner certification examination listed below.
2.
Certification examination title: ______________________________________________________________________________________
Certificate awarded: (Title) ________________________________________________________________________________________
Certificate number: __________________________________________
Date initial certificate awarded: _______ / _______ / _______
mo.
day
yr.
Is this nurse currently certified?
Yes
No
Expiration date: _______ / _______ / _______
mo.
day
yr.
3.
Education program that was basis for admission to the examination:
Program ______________________________________________________________________________________________________
Entrance date _______ / _______ / _______
Completion date _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Degree/diploma awarded: __________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Institution: ____________________________________________________________________________________________________
Address: ______________________________________________________________________________________________________
Certification
I hereby certify that to the best of my knowledge and belief the information in Section II is an accurate record of the examination results of
the individual named on this form.
Signature: ____________________________________________________________________
Date: _______ / _______ / _______
mo.
day
yr.
Print Name: __________________________________________________________________
Title: ________________________________________________________________________
Agency: _______________________________________________________________________
Address: ______________________________________________________________________
(SEAL)
_______________________________________________________________________
Telephone: _______________________________ Fax: _________________________________
E-mail Address: _________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Nurse Practitioner Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Nurse Practitioner Form 3, Page 2 of 2, (Rev. 3/09)
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