Clinical Nurse Specialist Form 1 - Application For A Clinical Nurse Specialist Certificate - 2016 Page 2
ADVERTISEMENT
1
2
3
411.
Identify the basis on which you are applying for a certificate.
a.
Holding a current license or certificate as a clinical nurse specialist issued by another state or country. (File Form 3 and Form 2)
Name of Government Issued License or Certification Name of Government Entity that Issued License or Certification
Education Program Title and Type of Degree
Education Institution Name
Date Graduated
Completion of a clinical nurse specialist master's degree, doctoral degree or post master's certificate program that is equivalent
b.
to a clinical nurse specialist program registered by the New York State Education Department and current certification as a
clinical nurse specialist by an approved national certifying organization (the AACN, ANCC, or ONCC). (File Form 2 and Form
3C)
Education Program Title and Type of Degree
Education Institution Name
Date Graduated
Title of Clinical Nurse Specialist Certification
Name of National Certification Organization
Date originally certified (Month/Day/Year)
Expiration Date of Current Certification (Month/Day/Year)
c.
Completion of a clinical nurse specialist educational program registered by the New York State Education Department as
qualifying for a certificate. (File Form 2)
Date Graduated
Education Program Title
Education Institution Name
12. Please print clearly giving an accurate record of your educational preparation below. You must complete all information for all
schools/colleges/universities attended and diplomas and/or degrees received or your application will be considered incomplete.
Attach additional sheets if necessary.
All Postsecondary Higher Education except Clinical Nurse Specialist Program(s)
Name of School
City
State/Province
Country
Major/Concentration
Number of years attended
Attendance from
to
mo.
mo.
yr.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language)
Date Degree/Diploma/Certificate awarded
mo.
yr.
Clinical Nurse Specialist Program(s)
Name of School
City
State/Province
Country
Major/Concentration
Number of years attended
Attendance from
to
mo.
mo.
yr.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language)
Date Degree/Diploma/Certificate awarded
mo.
yr.
Clinical Nurse Specialist Form 1, Page 2 of 4, Revised 6/17
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 0405-331.1 - Alaska Oil And Gas Production Tax Credit Application For A Transferable Tax Credit Certificate
Financial
Form 1 - Application For, And Amendments To Application For, Registration As A National Securities Exchange Or Exemption From Registration - 1999
Legal
Form Amp - Application For A Materialman To Remit Sales Tax Under The "pay When Paid" Method - 2016
Financial
Related Categories
Parent category: Legal