Apply for ACLPN 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 *
Suffix
Preferred pronouns *
Mailing address *
Apt/Suite
City *
State *
Zip code *
Country
Email *
Phone *
Current LPN/LVN 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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Area of professional HIV/AIDS emphasis *

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Primary practice setting *

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

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

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If yes, please supply certification expiration date (MM/DD/YYYY)
Did you take any organized review courses prior to starting the certification process? *

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Date (MM/YYYY)
Location

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

Candidate Agreement

Terms *
I have read and understand the requirements for candidate eligibility. 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.




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