Clinical Nurse Specialist Form 3c - Verification Of National Clinical Nurse Specialist Certification
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1
2Department Use Only
The University of the State of New York
Clinical Nurse Specialist
THE STATE EDUCATION DEPARTMENT
Approved
Office of the Professions
Form 3C
Division of Professional Licensing Services
Date
Verification of National Clinical Nurse Specialist Certification
(Use this form ONLY if you are seeking a New York State certificate through a national certifying organization.)
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 9.
2.
Send the entire form to the national clinical nurse specialist certifying organization. Ask it 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 other party.
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
3.
Print Name as It Appears on Your Application for a Clinical Nurse Specialist Certificate (Form 1)
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.
National clinical nurse specialist certifying organization: _______________________________________________________________
Certification examination passed: Title: ____________________________________________ Date: ________ / ________ / ________
mo.
day
yr.
7
Are you currently certified? Yes No
7.
If yes, certification number: ______________________________________________ Expiration date: ________ / ________ / ________
mo.
day
yr.
8
8
Print name under which certificate was awarded (if different from above).
Name: _______________________________________________________________________________________________________
9
9.
I request and give my permission to the national certifying organization listed in item 6 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 3C, Page 1 of 2, August 2014
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