NATIONAL CERTIFICATION EXAMINATION APPLICATION

Please complete the following application and return to the American Board of Comprehensive Care. Application must be received by Monday November 25, 2013. The application fee is $250.

General Information
Last 4 digits of your Social Security number
Date of Birth (mm/dd/yyyy)
Gender: Male Female
Name: First Middle Last
Address Apt.
City State Zip
Phone: Daytime Work  
Email

RN Licensure
State(s) of RN Licensure License Number Expiration date of current licensure

APN State Licensure/Registration
If you are not currently licensed or registered, please indicate expected date of licensure/registration:
State(s) of APN Licensure/Registration Specialty License/Registration Number Expiration date of current License/Registration

APN Certification
If you are not currently certified, please indicate expected date of certification:
Organization Specialty Certification number Date certified Expiration date of current certification

DNP Program
Institution
(CCNE or NLNAC accredited school of nursing)
Address
City State Zip

 

Doctoral Program
Institution
Address
City State Zip


Payment
Enclosed is my check or money order payable to: American Board of Comprehensive Care
Charge my credit card
  Credit Card No. Expiration Date (mm/yyyy)
  Print Name on Card Signature __________________________________

CHECK LIST FOR COMPLETION AND ENCLOSURES:
Official Transcript from your DNP program (if you have not completed your DNP program prior to the application deadline, send an official transcript of work to date. Documentation of program completion will be required in order to sit for the exam and must be received by November 25, 2013.)
Verification of current RN licensure
Verification of APN certification
Verification of APN state licensure/registration
All items on application are completed
All documentation is included
Application is signed

Exam Accommodations

I need special exam accommodations and will submit a Test Accommodation Request Form and medical report.

Yes No
(Please see http://www.abcc.dnpcert.org/testAccom.shtml for further information on exam accommodations.)

Comments/Additional Information

Mailing Instructions
Type or print legibly using either black or blue ink. Submit an application, copy of RN license, copy of APN certification, and payment. Remember to attach all required supporting documents.
The final deadline is November 25, 2013. The completed application, supporting material, and fee must be received by this date.

If you are using regular mail delivery, please send to:

The American Board of Comprehensive Care
Box 6
630 West 168th Street
New York, NY 10032

If you wish to use FedEx, please address to:

The American Board of Comprehensive Care
617 West 168th Street
Rm. 252
New York, NY 10032

For questions & inquiries contact the American Board of Comprehensive Care at 212-305-3254, email abcc@dnpcert.org or visit the website at abcc.dnpcert.org

I certify that all the information contained in this application is true and correct. Misstatement of any material fact submitted may be sufficient cause for ABCC to bar me from the examination, to invalidate the results of my examination, to withhold certification, to revoke certification, or to take other appropriate action.

_______________________________________________
Signature
_________________________
Date

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