Fillable AGNP Conversion Application

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AGNP Conversion Application

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  • 16 check-boxes
  • 46 other fields

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AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD
–ANP/GNP
CONVERSION 01.01.17
WWW.AANPCERT.ORG
1
CONVERSION APPLICATION FOR ADULT-GERONTOLOGY NURSE PRACTITIONER
Eligibility Requirements:
• AANPCB Certificants dual-certified as both an Adult Nurse Practitioner (ANP-C) and a
Gerontologic Nurse Practitioner (GNP-C) may apply for Conversion of their ANP and GNP
certifications to the Adult-Gerontology Primary Care Nurse Practitioner (A-GNP)
• Current AANPCB ANP and GNP Certification numbers must be provided to verify eligibility
• Both ANP and GNP certifications with AANPCB must be current
• Current RN license with expiration date must accompany this application
Information:
• Nurse practitioners currently certified as an ANP or a GNP should check with their State Board of
Nursing for regulatory requirements regarding their certification and licensure
• Certificants will receive a new wall certificate and wallet card with the new credential
• Certificants meeting eligibility for conversion and certified by AANPCB as an Adult-Gerontology Primary Care
Nurse Practitioner are entitled to continue to use the credential NP-C and may use the new credential A-GNP-C
PLEASE PRINT NEATLY. Unique Identifiers are established for all applicants. The month and day of your birth, and last four numbers
of the applicant’s Social Security Number are required to process all applications. Legal given name must match the identification used
for verification and admittance to the testing center.
Month & Day of Birth (mm/dd): Last 4 of SSN:
AANPCB Adult NP
Certification Number:
A-
AANPCB Gerontology NP
Certification Number:
G-
AANP Membership # (if applicable):
First Name: Middle: Last:
Address:
City: State: Zip:
Phone: Cell Home Work
Email Address:
CURRENT RN LICENSURE (May be accessed from your SBON online verification system)
State RN/APRN License Number Date Of Expiration
For Office Use
www.aanpcert.org Toll-free: (855) 822-6727
certification@aanpcert.org PO Box 12926, Austin, TX 78711-2926
STATE BOARD OF NURSING NOTIFICATION FORM
Conversion of Adult NP (ANP) & Gerotologic NP (GNP)
to the Adult-Gerontology Primary Care NP (AGNP)
1. AANPCB does not charge a verification fee to send status results to State Boards of Nursing.
2. Return completed SBON Notification Forms to AANPCB via fax, mail, or email. Please print clearly.
3.
State Boards of Nursing may request notification of Certification, Failure, or
Expiration Status.
⎕ Notify the following State Board of Nursing of the Status of my current AANPCB National
Certification.
⎕
Adult-Gero Primary Care NP
My AANPCB Certification Numbers are (begins with A, G, AG):______________________________
STATE BOARD OF NURSING (SBON) INFORMATION
Na
me of SBON:
Address:
City: State: Zip Code:
Note:
CANDIDATE/CERTIFICANT INFORMATION
Full Name:
Address:
City: State: Zip Code:
Last 4 of SSN: MM/DD of Birth (e.g.; 01/23):
Signature:
Date:
BONForm.01.01.17
Main: (512) 637-0500
Fax: (512) 637-0540
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AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD
–ANP/GNP
CONVERSION 01.01.17
WWW.AANPCERT.ORG
2
CONVERSION APPLICATION FEE*
⎕ Conversion Fee $50.00
⎕ Paper Application Processing Fee $50.00
TOTAL:
*Fee includes a nonrefundable administrative paper application fee. Fees are subject to change without notice.
ATTESTATION STATEMENT FOR ANP/GNP CONVERSION
I certify that all the information I have provided on all pages of this Conversion Application is true and correct. I further
understand that timely submission of all supporting or required documentation, including applicable fees, is necessary for
the processing of my application. I acknowledge that I have accessed the AANPCB Certificant Handbook online and accept
all policies as outlined in the Handbook. I understand that all information I provide will be kept confidential and shall not be
used for any other purpose without my permission.
Signature: Date:
CONVERSION APPLICATION CHECKLIST
⎕ Application completely filled out
⎕ Name on application matches the names on Certificant’s current AANPCB certificates
⎕ Both Adult and Gerontologic Nurse Practitioner Certification numbers are provided
⎕ Copy of current RN license or online verification of RN license attached to application / sent to AANPCB
⎕ Application signed & dated
⎕ Fee payment attached (check) or information filled out (credit card)
⎕ Keep a photocopy of your application for your records
Completed paper applications, RN licenses, and correspondence may be faxed or emailed to:
Fax: (512) 637-0540 Email: Certification@aanpcert.org
Certification Administration numbers:
Main: (512) 637-0500 Toll: (855) 822-6727
Completed paper applications and RN licenses may be mailed to AANPCB at:
Capitol Station, LBJ Building, P.O. Box 12926 Austin, TX 78711-2926
$
Enclosed is my check payable to:
American
Academy
of
Nurse
Practitioners
Certification
Board
(AANPCB
)
Check #: Money Order #:
Charge my credit card:
☐
Visa
☐
MasterCard
☐
Amex
☐
Discover
Name on Credit Card (Please print):
Card # Expiration Date:
Signature:
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AGNP Conversion Application

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Completed 19 July 2020

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