Fillable Nurse Practitioner Form 2 Certification of Professional Education (New York State Education Department)

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Nurse Practitioner Form 2 Certification of Professional Education (New York State Education Department)

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The Nurse Practitioner Form 2 Certification of Professional Education (New York State Education Department) form is 2 pages long and contains:

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The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Nurse Practitioner Form 2
Certification of Professional Education
Applicant Instructions
1. Complete Section I. In item 4, enter your name exactly as it appears on your Application for Certificate (Form 1). Be sure to sign and
date item 11.
2. Send the entire form to the institution(s) you attended. Ask the registrar to complete Section II and forward both pages of the form in
an official school envelope directly to the Office of the Professions at the address at the end of this form. Be sure to include any fee
required by the institution. This form will not be accepted if submitted by the applicant or any party other than the school
official.
3. You must submit a separate Form 2 for each specialty area in which you are requesting a certificate.
Section I - Applicant Information
1. Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2. Birth Date
Month Day Year
3. New York State Registered Professional Nurse License Number
4. Print Your Name Exactly As It Appears On Your Application for a Certificate (Form 1)
Last
First
Middle
5. 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. Name as it appears on your degree or diploma
7. School attended
(Name)
(city/state or country)
8. Name of degree of diploma
9. Nurse Practitioner specialty area
Acute Care Adult Health College Health Community Health Family Health
Gerontology Holistic Care Neonatology Obstetrics/Gynecology Oncology
Pediatrics Palliative Care Perinatology Psychiatry School Health
Womens Health
10. Date degree/diploma awarded
mo. day yr.
11. I request and give my permission to the school listed in item 7 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 Date
Nurse Practitioner Form 2, Page 1 of 2, Revised 3/18
Section II - Verification of Nurse Practitioner 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 accepted 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.
a. It is hereby verified that
(see Section I, item 6)
has completed a program qualifying for certified nurse practitioner and the degree/diploma listed below has been awarded. The official
program title completed by the applicant is as follows:
Official program title
b. The program contained hours of classroom instruction and hours of preceptorship with a nurse practitioner or physician
c. Program completion date
mo. day yr.
d. Degree/diploma awarded
date
yr.daymo.
e. The individual named has completed a pharmacotherapeutics component of not less than three semester hours or the equivalent,
including instruction in drug management of clients in the nurse practitioner's concentration/specialty area.
Yes No
Yes No
f. The individual named has completed a pharmacotherapeutics component, including instruction in New York State and Federal laws related
to prescriptions and record keeping.
Certification - To be completed by the Registrar
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
Print Name
Institution
Address
Telephone Fax
Email
Institution Seal
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. OR, Submit this form to the Department by E-mail at
DPLSEduc@nysed.gov.
.
Nurse Practitioner Form 2, Page 2 of 2, Revised 3/18
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Nurse Practitioner Form 2 Certification of Professional Education (New York State Education Department)

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Completed 10 February 2022

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