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:  
Fax:  
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)
Card Type: MasterCard   Visa   American Express
Credit Card #:
Expiration Date:
3 Digit CVV2 Code on Back of Card:
Cardholder Name:
Billing address is same as above:
Credit Card Billing Address:
City:
State:
Zip:
If you are mailing or faxing this to us please have cardholder sign here:
Please Send Receipt by: Fax number from above
Fax to
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 is:  Attached    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