SUMMARY OF CONTINUING EDUCATION ACTIVITIES
MANAGED CARE NURSE (CMCN)  and  Managed Care Professional (CMCP)
CERTIFICATION RENEWAL PROGRAM

CREDENTIAL#: (the # on your certificate.  If one is not available, please use the last four digits of your SSN#)

CE hours for period of January 1,, forward.

       
Last Name: First Name, M.I:
(If name has changed since examination or last certification renewal, please include previous name and documentation to verify change.)
Mailing Address: City:
State: Zip:
Work Phone: Home Phone:
Email:    
Is this a change from a previous address? Yes No Nursing License #:
Social Work License #:

State Of Licensure:

       
CE Category* Program Title Program Sponsor Location: City & State Program Start/End Dates
or Completion Date
CE Hours


CE Categories:
*(Enter Roman Numeral)
 

 I.    Academic Courses
 II.   Self-Study
 III.  Seminar Attendance
 IV. Speaking Engagements/Workshops Presented

Total hours submitted:
(minimum 25 hours; listing
more than 25 is not needed)


Total #:

       
Renewal Fee: $55 is Before Deadline  
If Paying by Check, Check #: Payable to ABMCN
When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction.
 
Paying by Credit Card: To pay by credit card please click submit at bottom of page
If you are paying by credit card and the cardholder name is different than applicant name above, please enter cardholder name here: 
 
If you are mailing or faxing this to us please have cardholder sign here:
     

If you are mailing or faxing this application and if postmarked with check or faxed with credit card by January 31 following your credential expiration date, the fee is $55 USD. If sent AFTER January 31 following your credential expiration date, the fee is $80 USD (which includes the late charge).  Mail your completed form and fee to ABMCN, 4435 Waterfront Drive, Ste. 101, Glen Allen, Virginia 23060, (804) 527-1905. If paying by credit card, you may fax (804) 747-5316 or mail your form. If you send your form by fax, DO NOT MAIL the original as this may result in second charge to your credit card. The fee covers review of CE activities submitted for this cycle and services provided to ABMCN during the three-year cycle just completed and is not refundable. ABMCN Tax ID # 54-1905803

 Attention:
I hereby verify the truth of the entries on this Summary of Continuing Education Activities Form. I affirm that I participated in the activities listed and that the number of CE hours represented the actual number of education hours I completed. If the provider obtained prior approval of the activity for CMCN CE, the number of hours listed is the same as that pre –approved by ABMCN.

My current license can be found at this website:

   
 
Date Submitted

Signature (mandatory)