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

 


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1. Applicant Information  (*=Required Field)
Last Name For Certificates:*  
First Name For Certificates:*  With Middle Initial if Desired
Last Name on License:
(If different from above)
 
First Name on License:
(If different from above)
 With Middle Initial if Desired
Title*:  
Organization:*  
Address:*  
City:*   
State:*  
Zip:*  
Address is:*  Organization  Home
Education/Degrees Acquired:*  RN   LVN      LPN    LCSW    MCSW
Phone:*  
Email:*  
Specialty:  
 Last 4 digits of your SSN:*  
License Number:
Please fax your license to 804-747-5316 or mail to address below
 
State of Licensure:  
Years of Experience in managed care:  
Member of AAMCN: Yes   No
2. Payment
  Certification Examination Fee is $250.00  
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:
 
 
3. Affidavit

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

Dates:
Signature:
Date:
The Name of My Proctor for the Examination is:
My Proctor's Phone Number:
Proctor Application: Will be faxed to 804-747-5316
Will be mailed to address below

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.
 

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 or mail 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