THE AMERICAN COLLEGE OF LEGAL NURSE CONSULTING
APPLICATION FOR CERTIFICATION
Application for Certification by: _____ Examination _____ Reciprocity _____ Practice Experience
Name:____________________________________________________________________ Date :_____________
City:____________________________________ State:_____________ Zip:____________________________
LNC School or Educational Program Attended:____________________________________________________
Date of Completion:_________________________________ Number of hours of instruction:______________
Applicants must submit one of the following: 1) a copy of their certificate of completion, or 2) an official letter by the school, educational program, or instructor verifying successful completion of the program and the number of contact hours of the educational 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 conversion: 50 minutes = 1 contact hour. 1 semester unit of college credit = 15 contact hours.
For Applicants applying for Reciprocity
Organization or Certifying Body you are currently certified by:_______________________________________
Date of certification:__________________________________ Date of expiration:________________________
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
If self employed, name of business:_______________________________________________________________
City:__________________________________ State:__________________ Zip:_________________________
Number of hours of practice as an LNC within a four year period from this date of application:___________
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 # 4, Waren, Ohio 44484.
List all degrees/credentials earned to date: _____________________________________________________________________________________________
Method of Payment
Application fee for 4 year term of certification is $ 200.00
_____ Money Order
_____ Credit Card _____ Visa _____ MC
Card Number:____________________________________________________ Expiration:_________________
Name on Card:___________________________________________________ Signature:___________________
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 provided 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 untrue statements on this application, or misrepresented myself, or have provided fraudulent documentation to the ACLNC, that the ACLNC may rescind my certification and fellowship status.