Clinical Nurse Specialist Form 1 - Application For A Clinical Nurse Specialist Certificate - 2016
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The University of the State of New York
Clinical Nurse Specialist Form 1
The State Education Department
Office of the Professions
Application for a Clinical Nurse Specialist Certificate
Division of Professional Licensing Services
Applicants Must Complete All Pages Of This Application In Ink
1.
22
$80
IP
All applicants for a certificate must complete this form and submit it with the $80 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 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.
2.
Social Security Number
3.
Birth Date
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
4.
Print Name
(This must be the same name as on your RN license)
6.
Telephone/Email Address
Last
Daytime Phone
Home or
Business
First
Middle
Area Code
Phone
Licensee business address, phone and email address are public information. Failure to
Email Address (please print clearly)
indicate business or home on this form for each item will deem it public information.
5.
Mailing Address
Home or
Business
Home or
Business
(You must notify the Department promptly of any address or name changes)
7.
New York State DMV ID Number
Line 1
(Driver or Non-Driver ID)
Line 2
Line 3
(Leave this blank if you do not have a
City
New York State DMV ID Number)
State
ZIP Code
Country/
Province
8.
New York State Registered Professional Nurse License Number
Name(s) under which credentialed (if different from above)
9.
Name as it appears on degree or other credentials (if different from above)
10. Specialty area for which you are applying (check only one)
Adult Health
Oncology
Pediatrics
Psychiatry
Clinical Nurse Specialist Form 1, Page 1 of 4, Revised 6/17
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