HANCB AACRN 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.

First name *
Middle initial
Last name *
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 *

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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 in past 5 years *

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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 AACRN program? *
Are you currently a member of ANAC? *

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If yes, enter your member ID number
Do you/will you receive a monetary reward for certification? *

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Is certification part of the job performance/clinical ladder rating criteria? *

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Are you currently or have you been certified in HIV/AIDS nursing (ACRN)? *

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Are you currently or have you been certified in Advanced HIV/AIDS Nursing (AACRN)? *

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Have you taken this exam before? *

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Optional Information


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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

Experience Validation

The person named below (my nursing supervisor or professional colleague), has verified that the above named candidate for the Specialty Certification Examination in Advanced HIV/AIDS Nursing Practice has a minimum of 2000 hours of HIV/AIDS nursing experience within the five years prior to application.

Name *
Relationship to candidate *
Phone *

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.

Fields marked with * are required.

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