The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
Nurse Practitioner Form 2C
Verification of Pharmacotherapeutics Course
(Three Semester Hours of the Equivalent)
Use this form ONLY if you have completed a program other than program
registered by the New York State Education Department as qualifying for a certificate.
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 8.
2. Send the entire form to the school/institution/professional association where you completed a pharmacotherapeutics course, including
instruction in drug management of clients in the nurse practitioner’s specialty area. 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.
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)
5. Mailing Address (You must notify the Department promptly of any address or name changes)
State ZIP Code
6. Print name under which course was completed (if different from above)
7. Name of school/institution/professional association where course was completed
8. I request and give my permission to the school/institution/professional association 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 2C, Page 1 of 2, Revised 5/17