American Board of Comprehensive Care

Mailing Instructions
Type or print legibly using either black or blue ink. Submit an application, copy of RN license, copy of APN certification, and payment. Remember to attach all required supporting documents.
The final deadline is Monday, June 11, 2012. The completed application, supporting material, and fee must be received by this date.

If you are using regular mail delivery, please send to:

The American Board of Comprehensive Care
Box 6
630 West 168th Street
New York, NY 10032

If you wish to use FedEx, please address to:

The American Board of Comprehensive Care
617 West 168th Street
Rm. 252
New York, NY 10032

For questions & inquiries contact the American Board of Comprehensive Care at 212-305-3254, email abcc@dnpcert.org or visit the website at abcc.dnpcert.org

I certify that all the information contained in this application is true and correct. Misstatement of any material fact submitted may be sufficient cause for CACC to bar me from the examination, to invalidate the results of my examination, to withhold certification, to revoke certification, or to take other appropriate action.

_______________________________________________
Signature

_________________________
Date

PRINT FORM

General Information
Last 4 digits of your Social Security number
Date of Birth	(mm/dd/yyyy)
Gender:	Male Female
Name:	First	Middle	Last
Address		Apt.
City		State	Zip
Phone: Daytime		Work
Email

RN Licensure
State(s) of RN Licensure	License Number	Expiration date of current licensure

APN State Licensure/Registration
If you are not currently licensed or registered, please indicate expected date of licensure/registration:
State(s) of APN Licensure/Registration	Specialty	License/Registration Number	Expiration date of current License/Registration

APN Certification
If you are not currently certified, please indicate expected date of certification:
Organization	Specialty	Certification number	Date certified	Expiration date of current certification

DNP Program
Institution	(CCNE or NLNAC accredited school of nursing)
Address
City	State Zip

Payment
	Enclosed is my check or money order payable to: American Board of Comprehensive Care
	Charge my credit card	Visa Mastercard
	Credit Card No.		Expiration Date (mm/yyyy)
	Print Name on Card		Signature __________________________________

CHECK LIST FOR COMPLETION AND ENCLOSURES:
	Official Transcript from your DNP program (if you have not completed your DNP program prior to the application deadline, send an official transcript of work to date. Documentation of program completion will be required in order to sit for the exam and must be received by June 28.)
	Verification of current RN licensure
	Verification of APN certification
	Verification of APN state licensure/registration
	All items on application are completed
	All documentation is included
	Application is signed

Exam Accommodations
I need special exam accommodations and will submit a Test Accommodation Request Form and medical report.	Yes No
(Please see http://www.abcc.dnpcert.org/testAccom.shtml for further information on exam accommodations.)

Comments/Additional Information

NATIONAL CERTIFICATION EXAMINATION APPLICATION