Fillable (Three Semester Hours of the Equivalent) Verification of (New York State Education Department)

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(Three Semester Hours of the Equivalent) Verification of (New York State Education Department)

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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 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.
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 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)
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. Print name under which course was completed (if different from above)
7. Name of school/institution/professional association where course was completed
Address
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
Section II - Verification of Completion of Pharmacotherapeutics Course
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 6)
has completed pharmacotherapeutics instruction in drug management of clients in the nurse practitioner's specialty area of
2. This course was
part of a nurse practitioner program, or
supplementary course.
3. The inclusive date(s) of the course were
mo. day yr.
and
mo. day yr.
4. The length of the course was
(semester hours)
or
(clock hours)
5. In this course, did the individual named receive instruction in New York State and Federal laws relating to prescriptions and record
keeping?
Yes No
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
pharmacotherapeutics by 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 2C, Page 2 of 2, Revised 5/17
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(Three Semester Hours of the Equivalent) Verification of (New York State Education Department)

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Completed 6 February 2022

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