HANCB ACRN Certification application

Please complete all of the following required information and make your payment using Paypal. If you would like to pay without using Paypal, please complete the downloadable application. This application can be returned by fax to 330-670-0109, email or mail.

Title
First name *
Middle initial
Last name *
Suffix
Mailing address *
Apt/Suite
City *
State *
Zip code *
Email *
Phone *
Current RN License Number *
License state *
License expiration date (mm/dd/yyyy) *

Eligibility and Background Information

Percent of working time currently spent in HIV/AIDS nursing *

Clear Selection
Primary position *

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Primary practice setting *

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Area of professional HIV/AIDS emphasis *

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Experience in HIV/AIDS nursing *

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Employment status *

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Primary practice location *

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Highest academic level *

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Other certifications held *
How did you hear about the ACRN program? *
Are you currently a member of ANAC? *

Clear Selection
If yes, enter your member ID number
Are you currently or have you been certified in HIV/AIDS nursing? *

Clear Selection
Have you taken this exam before? *

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Did you take the online assessment test prior to taking the certification exam? *

Clear Selection
Did you take any organized review courses prior to taking the certification exam? *

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Have you taken any other ACRN prep course? *

Clear Selection

Optional Information

Race

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Age

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Gender

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Required Documentation

Please attach a copy of your current RN license(s) here. If you are unable to upload a copy of your license(s), a copy may be faxed to the national office at 330.670.0109.

File 1
File 2
File 3

Candidate Agreement

Terms *
I have read and understand the requirements for candidate eligibility and the cancellation, rescheduling and no show policies. I affirm that all statements given on this application are true and correct to the best of my knowledge and that HANCB is hereby authorized to contact any organization or individual listed hereon to verify my education and licensure history.






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