AACRN Application

Please complete all of the following required information.  Please note that we use Paypal as our payment gateway.  If you do not have a Paypal account, you may make payments as a guest user without creating an account.  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. 

Candidate Information
Mr
Mrs
Ms
Dr
(mm/dd/yyyy)

Eligibility and Background Information
Less than 25%
25% to 50%
51% to 75%
More Than 75%
Staff Nurse/Clinician
Head Nurse/Manager
Case Manager/Coordinator
Nurse Practioner
Clinical Nurse Specialist
Patient Educator
Nurse Educator/Faculty Member
Director/Assistant Director
Nurse Researcher
Infection Control Practitioner
Consultant
Sales/Marketing Industry Rep
Counselor
Other
Adult
Pediatrics
Hospital
Outpatient/Amubulatory
Public/Community Health
Hospice
Home Care
School of Nursing
Private/Group Practice/Physician's Office
Substance Abuse Treatment Center
Longterm Care Facility
Forensic Setting (jail, prison)
Community Base Organization
HIV Testing Center
Primary Prevention Program
Clinical Trial Group
Family Planning/STD Clinic
Other
2000 Hours
2 Years
3 - 6 Years
7 - 10 Years
More Than 10 Years
Full Time
Part Time
Unemployed
Retired
Rural
Suburban
Mixed
Urban (less than 1 million population)
Urban (more than 1 million population)
Not Applicable
None
AOCN
CIC
CCNS
CEN
Hospice
BC
Other
Master of Science with Concentration in Nursing (MS)
Master of Science in Nursing (MSN)
Master of Nursing (MN)
Master of Arts in Nursing (MA)
Master of Public Health in Community/Public Health Nursing (MPH)
Doctor of Nursing Science (DNSC or DSN)
Doctor of Nursing Practice (DNP)
Doctor of Philosophy in Nursing (PhD)
Nursing Doctor (ND)
Other
ANAC Mailing
Colleagues
JANAC
ANAC Annual Conference
Local Chapter Meeting
Other Journals
Other
Yes
No
Yes
No
Yes
No
No
Yes, Currently Certified
Yes, Certification Lapsed
No
Yes, Currently Certified
Yes, Certification Lapsed
Yes
No

Optional Information
African American
Asian
Hispanic
Native American
White
Other
Under 25
25 to 29
30 to 39
40 to 49
50 to 59
60+
Male
Female
Transgender

Documentation
Please attach a copy of your current RN license(s) and transcripts here. If you are unable to upload the necessary documents, copies can be faxed to the National Office at 330-670-0109.
Please upload files with one of the following extensions: doc, docx, xls, xlsx, pdf, txt
Verified

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.

Candidate Agreement

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 the HANCB is hereby authorized to contact any organization or individual listed hereon to verify my education and licensure history.

I agree

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