Apply for ACRN certification

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.

First name *
Middle initial
Last name *
Preferred pronouns *

Clear Selection
Mailing address *
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 *

Clear Selection
Primary practice setting *

Clear Selection
Area of professional HIV/AIDS emphasis *

Clear Selection
Experience in HIV/AIDS nursing *

Clear Selection
Employment status *

Clear Selection
Primary practice location *

Clear Selection
Highest academic level *

Clear Selection
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
If yes, please supply certification expiration date
Did you take any organized review courses prior to starting the certification process? *

Clear Selection

Optional Information


Clear Selection

Clear Selection

Clear Selection

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

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.

Applications are not considered complete until payment is received by HANCB. Pay through Paypal now.

Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

© 2021 HIV/AIDS Nursing Certification Board | 11230 Cleveland Ave NW #986, Uniontown, OH 44685
Phone: 800-260-6780 | Fax: 330-670-0109 | Email: