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Clinical Nurse Specialist Form 4 - Verification Of Experience - New York The State Education Department Page 2

Section II: Verification of Experience (Continued) - To be completed by the Clinical Supervisor

Certification

I certify that the information provided in Section II of this form is complete and accurate to the best of my knowledge and that I have

personally supervised the person named in this form in the performance of the competencies listed above.

Clinical Supervisor signature: ___________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Print name: ________________________________________________________________________

Title: ______________________________________________________________________________

New York State license number:

Profession: _________________________________________________________________________

Telephone: ___________________________________ Fax: __________________________________

E-mail: _____________________________________________________________________________

Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,

Clinical Nurse Specialist Unit, 89 Washington Avenue, Albany, NY 12234-1000.

Clinical Nurse Specialist Form 4, Page 2 of 2, Rev. 10/14

Clinical Nurse Specialist Form 4 - Verification Of Experience - New York The State Education Department Page 2