Nurse Practitioner Form 1 - Application For A Certificate - 2016
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4Department Use Only
The University of the State of New York
Nurse Practitioner
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 1
Division of Professional Licensing Services
Application for a Certificate
Applicants Must Complete All Pages of This Application In Ink
All applicants for a certificate must complete this form and submit it with the $85 fee for a certificate and initial registration
directly to the Office of the Professions at the address at the end of this form. You must answer all questions and provide all
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$85
ER
1
information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review.
You must sign and date the Affidavit on this form in the presence of a Notary Public.
NYS License Number
2
2.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Date Issued
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3.
Birth Date
Month
Day
Year
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4.
Print Name
Initials
(This must be the same name as on your RN license.)
Last
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6.
Telephone/E-Mail Address
First
Daytime phone
Middle
Home or Business
Licensee business address, phone and e-mail address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
Area Code
Phone
E-mail Address
(please print clearly)
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5.
Mailing Address:
Home or Business
Home or Business
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
6.
New York State DMV ID Number
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Line 3
(Driver or Non-Driver ID)
City
State
Zip Code
(Leave this blank if you do not have a New
Country/
York State DMV ID Number)
Province
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7.
New York State Registered Professional Nurse License Number:
Name(s) under which credentialed (if different from above): _____________________________________________________________
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8.
Name as it appears on degree or other credentials (if different from above): ________________________________________________
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9.
Nurse Practitioner specialty area for which you are applying:
Acute Care
Adult Health
College Health
Community Health
Family Health
Gerontology
Holistic Care Neonatology
Obstetrics/Gynecology Oncology
Pediatrics
Palliative Care
Perinatology
Psychiatry
School Health
Womens Health
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10. Identify the basis on which you are applying for a certificate. NOTE: A Form 1 & fee must be filed for each specialty area.
Name at time of graduation (if different from above): __________________________________________________________________
a.
Completion of nurse practitioner educational program registered by the New York State Education Department as qualifying for
a certificate. (File Form 2)
______________________________________ ___________________________________ __________________________
Program title (including specialty)
Institution
Date Graduated
b.
Completion of nurse practitioner educational program determined to be equivalent to a registered program by the State
Education Department as qualifying for a certificate. (File Form 2)
______________________________________ ___________________________________ __________________________
Program title (including specialty)
Institution
Date Graduated
c.
Verification of passing a nurse practitioner examination administered by a national certifying organization. (File Form 3)
______________________________________ ___________________________________ __________________________
Examination
Certifying agency
Date Graduated
Nurse Practitioner Form 1, Page 1 of 4, Rev. 6/16
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