Adult-Gerontology Primary Care Nurse Practitioner Certification Exam (AANPCP)

Important: This application is in addition to the application that must be completed on the AANPCP website. Please refer to AANPCP Fact Sheet for details.

Name

First Name

Middle Name

Last Name

Previous Surname(s)

Date of Birth

NSCN Registration Number

If you are not currently licensed as a registered nurse with NSCN, attach copy of your birth certificate. If name has changed, attach the applicable documentation.

Email Address

Phone Number

Address

Country

School of Nursing

City/Town/Province

for School of Nursing

Date of Entrance

Date of Completion

Have you ever written the AANPCP exam or other Pediatric NP exam?

Yes

If yes, how many times?

Name of NP Exam

Dates Written

Jurisdiction where exam was written

By submitting this application form:

I authorize the collection, use and disclosure of personal information concerning myself as described in the Nova Scotia College of Nursing (NSCN) Privacy Policy Statement. For more information on the privacy policy you can contact NSCN's privacy officer at 902-377-5122.

In addition, I authorize NSCN to carry out the procedures necessary for the assessment of my eligibility to write the Nurse Practitioner (NP) examination. This includes making copies of my application to write the NP examination and/or contacting the institutions or authorities stated on this application to verify the authenticity of the information. This Signature Declaration allows NSCN to contact other regulatory bodies and educational institutions to obtain information pertinent to my application. I agree that a copy of this Signature Declaration can be sent by NSCN to other regulatory bodies or educational institutions allowing them to release information to NSCN.

I declare that all of the information I have provided in this application is complete and truthful. I understand that NSCN will immediately stop the assessment of my application to write the NP examination and that my application will be cancelled, licensure will be refused, and I will be prohibited from applying to NSCN in the future if:

I have provided any inaccurate information; or
I have omitted required information. This applies to all written correspondence.