American Board of Managed Care Nursing
APPLICATION TO SIT FOR CMCN / CMCP EXAM

 


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1. Applicant Information
Last Name For Certificates:  
First Name For Certificates:  With Middle Initial if Desired
Last Name on License:  
First Name on License:  With Middle Initial if Desired
Title:  
Organization:  
Organization Address  
MailCode/Suite Number:  
Organization City:  
Organization State:  
Organization Zip:  
Home Address:  
City:   
State:  
Zip:  
Preferred Mailing Location:  Organization  Home
Education/Degrees Acquired  RN   LVN      LPN    LCSW    MCSW
Phone:  
Home:  
Email:  
Specialty:  
SSN:  
(Attach Copy) License Number:  
State of Licensure:  
Years of Experience in managed care:  
Member of AAMCN: Yes   No
2. Payment
Certification Examination Fee:
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.

 
If Paying with 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:
 
 
Please Send Receipt by: Email from above
Email to
3. Affidavit

I completed and submitted my post test of the  American Association of Managed Care Nurses  Preparatory course

Dates:
Location of Home Study:
Signature:
Date:
The Name of My Proctor for the Examination is:
My Proctor's Phone Number:
Location Where Exam Is To Be Taken:
Proctor Application: Coming under separate cover

4. Authorization

  I authorize the American Board of Managed Care Nursing (ABMCN) to use whatever it deems necessary to verify the statements I have made to the ABMCN. I accept that the ABMCN will treat all information regarding this form and my certification as confidential. I allow the ABMCN to use the data on this, or the examination, for statistical analysis and improvement of the ABMCN examination process. I declare all statements in my application are true and that to utter a false statement is grounds for denial or loss of the CMCN / CMCP credential.
I authorize the ABMCN to send by US mail my test results IN THE FORM OF PASS OR FAIL to the above address.
Upon passing the exam, I authorize ABMCN to send the following person appropriate press information for company newsletters, local newspapers and or letters of recognition.

Name:
Email:
Signature:
Date:
 

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If this application form is incomplete or if any required documentation is missing, your application will be returned to you.

OPTIONS:
ONLINE - You can submit this secure application online, however you will need to fax the completed Proctor Agreement Form and a copy of your current nursing license within 24 hours.

FAX or MAIL - You can print this page and fax or mail it with the completed Proctor Agreement Form and a copy of your current nursing license.

ABMCN, Application Department
4435 Waterfront Drive, Suite 101
Glen Allen, Virginia 23060, Tele 804/527-1905
Fax: 804/747-5316