AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD Rev. 05.16.19
P.O. Box 12926 Austin, TX 78711-2826
Main (512) 637-0500 Toll-free (8550 822-6727 Fax (512) 637-0540
Email: Certification@aanpcert.org www.AANPCERT.org
STATE BOARD OF NURSING NOTIFICATION ORDER FORM
DO NOT USE THIS FORM FOR 3
RD
PARTY CREDENTIAL PRIMARY SOURCE VERIFICATION
Important Information:
Fee: $0. AANPCB does not charge a fee to send certification status results to State Boards of Nursing.
Complete this form to notify a State Board of Nursing (SBON) of Initial, or Renewal of, Nurse Practitioner Board Certification.
This is a fillable PDF form. Download and save to your computer or print.
Complete required information and submit form to AANPCB via email, fax, or mail.
Questions about the SBON Notification Order Form? Contact the Verification Dept. at (512) 637-0500, ext. 576.
INFORMATION REQUIRED FOR PROCESSING OF SBON REQUEST (Please print clearly)
CANDIDATE / NURSE PRACTITIONER INFORMATION
Name (First Middle Last): Last 4 SSN:
Address: DOB (mm/dd):
City State Zip:
NAME(s) OF BOARD OF NURSING TO NOTIFY
1.
2.
Notes:
NEW INITIAL CERTIFICATION: Applicants Applying for Initial Nurse Practitioner Certification
Notify the above State Board(s) of Nursing that:
I am Eligible-to-Sit for the AANPCB certification examination. (check which exam)
I have recently taken the AANPCB certification examination (check which exam was
taken) and approve release of my certification status after my NP certification is
processed.
Adult-Gero Primary Care NP
Emergency NP
Family NP
RENEWAL OF CURRENT CERTIFICATION: Nurse Practitioners Currently Board-Certified by AANPCB
Notify the above State Board(s) of Nursing of:
My NP certification status as of today.
My NP certification after my certification
renewal application is processed.
NP SPECIALTY
CERTIFICATION NUMBER
Adult NP
A -
Adult-Gero Primary Care NP
AG -
Emergency NP
E -
Family NP
F -
Gerontologic NP
G -
NP Signature: Date:
click to sign
signature
click to edit
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