PAC Certification Application Form "*" indicates required fields Please select the criteria met for recertification* 20 hours of demonstrated on-the-job competency Minimum of 20 continuing education units in the past two years Minimum of 20 verifiable hours as a nurse preceptor in a post-acute Care setting Minimum of six credits hours earned from an accredited academic institution 20 hours of demonstrated consulting work in the Post-Acute Care setting InsPAC certification renewal examination with a passing score of 80% or higher Name* First Last Phone Number*Email (Work)* Email (Personal)* Organization name* Examination Type*Select Certification TypePAC-NEPAC-DONPAC-NLPAC-CSEPAC-RNPAC-LPNPAC-HHPPAC-CNAPAC-VCPAC-LNPJob Title*Select JobCNOVP NursingDON/DNSStaff EducatorInfection PreventionistAdministratorNurseCNANurse AssistantOtherOther* Highest Education*Highest EducationHigh schoolGEDBachelor's degreeMaster's degreeDoctorate or higherLicense Type*License TypeRNLPNCNANHAOtherType Other License* State of Issue*State of IssueAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStatus*StatusCurrentExpiredDisciplinary ActionOtherOther Status* Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Consent* I do hereby attest that this information is true, accurate and complete. I understand that any falsification, omission or concealment of material fact may subject my application or recertification to be revoked without a refund.*
