Nurse Practitioner Form 2b - Verification Of Instruction In New York State And Federal Laws Related To Prescriptions And Record Keeping Page 2
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2Section II: Verification of Completion of Prescription Course
Instructions to School/Institution/Professional Association: Please complete Section II and return both pages of this form directly to the
New York State Education Department at the address at the end of this form. This form will not be accepted if returned by the applicant
or any other party.
1.
It is hereby verified that: __________________________________________________________________________________________
(Section I, item 6)
completed instruction in New York State and federal laws related to prescriptions and record keeping.
2.
This course was:
part of nurse practitioner program, or
supplementary course.
3.
Date(s) of the course: _______ / _______ / _______
and
_______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
4.
The length of the course was: _______________________ or ______________________.
(semester hours)
(clock hours)
Attestation
I hereby attest that to the best of my knowledge and belief the information in Section II is an accurate record of the completion of a course in
prescription and record keeping laws of the individual named on this form.
Signature: ____________________________________________________________________
Date: _______ / _______ / _______
mo.
day
yr.
Print Name: __________________________________________________________________
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,
Nurse Practitioner Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Nurse Practitioner Form 2B, Page 2 of 2, (Rev. 3/09)
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