Clinical Nurse Specialist Form 2 - Certification Of Professional Education - New York The State Education Department

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Department Use Only
The University of the State of New York
Clinical Nurse Specialist
THE STATE EDUCATION DEPARTMENT
Approved
Office of the Professions
Form 2
Division of Professional Licensing Services
Date
Certification of Professional Education
Applicant Instructions
1.
Complete Section I. In item 4, enter your name exactly as it appears on your Application for a Clinical Nurse Specialist Certificate (Form
1). Be sure to sign and date item 11.
2.
Send the entire form to the institution(s) you attended. Ask the registrar to complete Section II and forward both pages of the form in an
official school envelope directly to the Office of the Professions at the address at the end of this form. Be sure to include any fee
required by the institution. This form will not be accepted if submitted by the applicant or any party other than the school official.
3.
You must submit a separate Form 2 for each specialty area in which you are requesting a certificate.
Section I: Applicant Information
1
2
1.
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
3.
New York State Registered Professional Nurse License Number
4
Print Name as It Appears on Your Application for a Clinical Nurse Specialist Certificate (Form 1)
Last
First
Middle
4.
5
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
5.
Print your name as it appears on your degree or diploma.
Name: ______________________________________________________________________________________________________
7
6.
School attended: ______________________________________________________________________________________________
(Name)
(city/state or country)
8
7.
Name of degree/diploma: _______________________________________________________________________________________
9.
9
Specialty area for which you are applying:
 Adult Health
 Oncology
 Pediatrics
 Psychiatry
10
8.
Date degree/diploma awarded: ________ / ________ / ________
mo.
day
yr.
11
9.
I request and give my permission to the school 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.
Clinical Nurse Specialist Form 2, Page 1 of 2, August 2014

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