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.

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 *

Clear Selection
Primary practice setting *

Clear Selection
Area of professional HIV/AIDS emphasis *

Clear Selection
Experience in HIV/AIDS nursing in past 5 years *

Clear Selection
Employment status *

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Primary practice location *

Clear Selection
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? *

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

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

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

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

Clear Selection
Have you taken this exam before? *

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

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.






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