NATIONAL CERTIFICATION EXAMINATION APPLICATION

Please complete the following application and return to the American Board of Comprehensive Care. Completed application, all supporting materials, and fee must be received by Monday, June 7, 2010.

EXAMINATION FEE: $250.00

General Information
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
State(s) of APN Licensure/Registration	Specialty	License/Registration Number	Expiration date of current License/Registration

APN Certification
Organization	Specialty	Certification number	Date certified	Expiration date of current certification

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DNP Program
Institution	(CCNE or NLNAC accredited school of nursing)
Address
City	State Zip
Program Director Name
Clinical Residency:	Yes No
Site of Residency		Length of Residency
Site of Residency		Length of Residency

Clinical Practice
How many years of clinical practice do you have?

GRE Scores Have you taken the GRE? Yes No   GRE Math GRE English GRE Writing/Analtyical Have you take any other standardized graduate school exam(s)? Yes No If yes, which standardized exam(s)? If yes, what was your score(s)?

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
	Payment enclosed (check signed or credit card number complete)
	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/examAccommo.shtml for further information on exam accommodations.)

Comments/Additional Information

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 7, 2010. 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

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