Nurse Practitioner Form 2c - Verification Of Pharmacotherapeutics Course

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Department Use Only
The University of the State of New York
Nurse Practitioner
THE STATE EDUCATION DEPARTMENT
Approved
Office of the Professions
Form 2C
Division of Professional Licensing Services
Date
Verification of Pharmacotherapeutics Course
(Three Semester Hours or the Equivalent)
(Use this form ONLY if you have completed a program other than program
registered by the New York State Education Department as qualifying for a certificate.)
Applicant Instructions
1.
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 8.
2.
Send the entire form to the school/institution/professional association where you completed a pharmacotherapeutics course, including
instruction in drug management of clients in the nurse practitioner’s specialty area. 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 party other than the school official.
Section I: Applicant Information
1.
Social Security Number
2.
Birth Date Month
Day
Year
1
2
(Leave this blank if you do not have a U.S. Social Security Number)
3.
New York State Registered Professional Nurse License Number
3
3.
Print Name as It Appears on Your Application for a Certificate (Form 1)
4
Last
First
Middle
5
4.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
6.
Print name under which course was completed (if different from above).
Name: ______________________________________________________________________________________________________
7
7.
Name of school/institution/professional association where course was completed: __________________________________________
Address: _____________________________________________________________________________________________________
8
8.
I request and give my permission to the school/institution/professional association listed in item 7 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.
_______________________________________________________________________________
________ / ________ / ________
Applicant’s Signature
mo.
day
yr.
Nurse Practitioner Form 2C, Page 1 of 2, (Rev. 3/09)

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