Fillable Nurse Practitioner Form 2B (New York State Education Department)

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Nurse Practitioner Form 2B (New York State Education Department)

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

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  • 40 other fields

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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 2B
Verification of Instruction in New York State and Federal Laws
Related to Prescriptions and Record Keeping
Applicant Instructions
1. Complete Section I. In item 4, enter your name exactly as it appear on your Application for Certification (Form 1). Be sure to sign and date
item 9.
2. Send the entire form to the school/institution/professional association where you completed instruction in New York State and federal laws
relating to prescriptions and record keeping. Ask them 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 party other than the school official.
Use this form ONLY if you have completed a program other than a program registered by the New York State Education Department
as qualifying for a certificate.
Use this form ONLY if you have completed a program located outside of New York State.
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. Print Name
Last
First
Middle
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
4. Mailing Address Home or Business
(You must notify the Department within 30 days of any address or name changes)
Line 1
Line 2
Line 3
City
State ZIP Code
Country/
Province
5. Telephone/Email Address
Daytime Phone
Home or Business
Area Code Phone
Email Address (please print clearly)
Home or Business
6. New York State DMV ID Number
(Driver or Non-Driver ID)
(Leave this blank if you do not have a
New York State DMV ID Number)
7. Print name under which course was completed (if different from above)
8. Name of school/institution/professional association where course was completed
Address
9. I request and give my permission to the school/institution/professional association listed in item 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
Signature Date
Nurse Practitioner Form 2B, Page 1 of 2, Revised 9/20
Section II: Certification of Professional Education
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 the form. This form will not be accepted if returned by the applicant or
any other party.
1. It is hereby verified that
(see Section I, item 7)
completed instruction in New York State and Federal laws related to prescriptions and record keeping.
2. This course was
part of a nurse practitioner program, or
supplementary course.
3. Date(s) of the course
mo. day yr.
and
mo. day yr.
4. The length of the course was
(semester hours)
or
(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
Print Name
Title or official position
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 2B, Page 2 of 2, Revised 9/20
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Nurse Practitioner Form 2B (New York State Education Department)

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Completed 6 February 2022

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