| Application for Certification by: |
Examination
Reciprocity
Practice Experience |
| Personal Information |
| Full Name: |
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| Mailing Address: |
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| Phone (Area code - Number): |
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| Fax (Area code - Number): |
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| E-Mail Address: |
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| Schooling or Education |
| LNC School or Educational Program Attended: |
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| Date of Completion (mm/dd/yy): |
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| Number of hours of instruction: |
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Applicants must submit one of the following:
- a copy of their certificate of completion; or
- a official letter by the school, educational program, or instructor verifying successful completion of the program and the number of contact hours of the education program. NOTE: if the certificate of completion does not have the number of contact hours detailed on it, then it is necessary to submit an official letter from the school, program or instructor verifying the number of hours or college credits earned.
For translation purposes, the ACLNC uses the following coversion: 50 minutes = 1 contact hour. One (1) semester unit of college credit = 15 contact hours. |
| For Applicants Applying for Reciprocity |
| Organization or Certifying Body you are currently certified by: |
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| Date of certification (mm/dd/yy): |
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Date of expiration (mm/dd/yy): |
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Candidates must submit a copy of their current certification certificate or a copy of their official letter of certification by the organization or certifying body. The ACLNC reserves the right to contact such organization or body and verify certification of the applicant. |
For applicants applying for Certification qualification
by practice experience |
| Employer: |
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| If self employed, name of the business: |
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| Number of hours of practice as an LNC within a three year period from the date of application: |
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Applicants must have two reference letters from current or former clients (attorneys, insurance company, etc.) attesting to the fact that the LNC had done work for them, and a short reference related to quality of work product. Reference letters must be sent directly to the office of the ACLNC. Applications will be considered pending until references are received.
Have references sent to:
American College of Legal Nurse Consulting
2400 Niles-Cortland Rd. S.E. Suite # 3
Warren, Ohio 44484 |
| List all degrees/credentials earned to date: |
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| Method of Payment |
| Please select a payment option: |
Check
Money Order
Credit Card
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Agreement
I, the undersigned, verify that this application is complete, and to the best of my knowledge, all information provided is factual and true. I understand that failure to provide the needed information and required documentation could likely lead to delays in the processing of this application. I further understand that if any information supplied on this application is false, that I will be denied consideration for certification. I further understand that if at any time it is discovered that I have made false or misleading statements on this application, or misrepresent myself, or have provided fraudulent documentation to the ACLNC, that the ACLNC may rescind my certification and fellowship status.
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| Your comments or Questions: |
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