Fillable State Board Of Nursing Notification Form

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State Board Of Nursing Notification Form

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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:
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State Board Of Nursing Notification Form

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Completed 19 July 2020

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