Please check your answer to the following questions: 1. Have you used, in the last three years, or do you currently use, alcohol or any drug in such a way as to impair competent and objective professional performance? Yes No If YES, please describe fully the circumstances ___ 2. Do you have any physical or mental condition which impairs competent and objective professional performance? Yes No If YES, please describe fully the circumstances ___ 3. Have you ever been adjudicated to have committed malpractice or gross or repeated negligence in the field of nursing? Yes No If YES, please describe fully the circumstances ___ 4. Have you ever had your certificate or license to practice subject to limitation, discipline, revocation or other sanction, including voluntary limitation, by a regulatory board or professional organization relating to public health or nursing? Yes No If YES, please describe fully the circumstances ___ 5. Have you ever been convicted or plead guilty to or plead nolo contendere to a felony or misdemeanor related public health or nursing? These include but are not limited to a felony involving rape or sexual abuse of a patient or child, and actual or threatened use of a weapon.) Yes No If YES please describes fully the circumstances ___ I hereby for Recertification as a Holistic Nurse, Nurse Coach, or Health and Wellness Nurse Coach offered by AHNCC. I understand that recertification depends upon meeting all eligibility criteria. I understand that information supplied is subject to audit and that failure to respond to a request for further information may be sufficient cause for AHNCC to invalidate the result of my certification, to revoke certification, to withhold recertification, or to take other appropriate action. I further understand that the information acquired in the recertification process may be used for statistical purposes and for the evaluation of the certification program. To the best of my knowledge, the information supplied in this Application for Recertification is true, complete, correct, and is made in good faith. Furthermore, by
Please check your answer to the following questions: 1. Have you used, in the last three years, or do you currently use, alcohol or any drug in such a way as to impair competent and objective professional performance? Yes No If YES, please describe fully the circumstances ___ 2. Do you have any physical or mental condition which impairs competent and objective professional performance? Yes No If YES, please describe fully the circumstances ___ 3. Have you ever been adjudicated to have committed malpractice or gross or repeated negligence in the field of nursing? Yes No If YES, please describe fully the circumstances ___ 4. Have you ever had your certificate or license to practice subject to limitation, discipline, revocation or other sanction, including voluntary limitation, by a regulatory board or professional organization relating to public health or nursing? Yes No If YES, please describe fully the circumstances ___ 5. Have you ever been convicted or plead guilty to or plead nolo contendere to a felony or misdemeanor related public health or nursing? These include but are not limited to a felony involving rape or sexual abuse of a patient or child, and actual or threatened use of a weapon.) Yes No If YES please describes fully the circumstances ___ I hereby for Recertification as a Holistic Nurse, Nurse Coach, or Health and Wellness Nurse Coach offered by AHNCC. I understand that recertification depends upon meeting all eligibility criteria. I understand that information supplied is subject to audit and that failure to respond to a request for further information may be sufficient cause for AHNCC to invalidate the result of my certification, to revoke certification, to withhold recertification, or to take other appropriate action. I further understand that the information acquired in the recertification process may be used for statistical purposes and for the evaluation of the certification program. To the best of my knowledge, the information supplied in this Application for Recertification is true, complete, correct, and is made in good faith. Furthermore, by
RECERT-APPL-2-9-2018.docx