Clinical Nurse Specialist Form 3 - Verification Of Other Professional Licensure/certification - 2014 Page 2
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2Section II: Verification of Other Professional Licensure/Certification
Instructions to the Licensing/Certifying Authority: Please complete items 1-4, sign and date the certification and return both pages of
this form in an official envelope directly to the Office of the Professions at the address below. This form will not be accepted if returned
by the applicant. Attach additional sheets if necessary.
1.
Name of applicant: ____________________________________________________________________________________________
(Section I, item 6)
2.
Professional title on license/certificate: _____________________________________________________________________________
License/certificate number: ____________________________________
Date of licensure/certification: _______ / _______ / _______
mo.
day
yr.
3.
Verification of licensure/certification
What requirements did the applicant meet to become licensed/certified in your jurisdiction?
Education:
Degree: ___________________________________________________________________________________________
Examination: Examination Title: _____________________________________ Date: _______ / _______ / _______ Score: __________
mo.
day
yr.
Experience: None
___________ hours
Describe (i.e., clock hours) ________________________________________
Endorsement of license from or reciprocity with: ______________________________________________________________________
(name of jurisdiction)
Yes
No
4.
A.
Has the applicant identified in Section I been subject to any disciplinary action?
Yes
No
B.
Are any charges pending against this individual?
If the answer to either A or B is "yes," please attach a complete explanation with any supporting documentation.
Certification
I hereby certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named above. I
further certify that, except as noted in item 4 above or in any attachments, this licensing authority has never taken any disciplinary action
against this person and that in so far as the licensing authority has knowledge, there have been no charges preferred nor has any
information been presented relating to any question of unprofessional or immoral conduct.
Signature: _____________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print name: ____________________________________________________________________
Title: _________________________________________________________________________
Licensing/certifying authority: ______________________________________________________
(SEAL)
Address: ______________________________________________________________________
______________________________________________________________________
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 3, Page 2 of 2, July 2014
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