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

Section II: Verification of Clinical Nurse Specialist Program

Instructions to Registrar: Please complete Section II and return both pages of this form along with an official school transcript, directly

to the New York State Education Department at the address at the end of this form. This form will not be accept-

ed if returned by the applicant or any other party.

Note: If the applicant has completed more than one program, a Form 2 must be submitted for each program.

It is hereby verified that: _________________________________________________________________________________________

(Section I, item 6.)

has completed a program qualifying for clinical nurse specialist and the degree/diploma listed below has been awarded. The official pro-

gram title completed by the applicant is as follows:

Official program title: ___________________________________________________________________________________________

The program contained: ___________ hours of classroom instruction and ___________ hours of preceptorship with a clinical nurse

specialist or physician.

Degree/diploma awarded: _________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Certification

I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the

professional education of the individual named on this form.

Signature of Registrar: ___________________________________________________________

Date: _______ / _______ / _______

mo.

day

yr.

Title or official position: __________________________________________________________

Institution: _____________________________________________________________________

Address: ______________________________________________________________________

(SEAL)

_______________________________________________________________________

Telephone: _______________________________ Fax: _________________________________

E-mail Address: _________________________________________________________________

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 2, Page 2 of 2, August 2014

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