Alabama State Nurses Association Approved Provider Eligibility Verification Section 1: Demographic Data Organizations interested in submitting an application for approval as an Approved Provider must complete the Eligibility Verification and meet all Eligibility Requirements. Verification received from organizations that do not meet Eligibility Requirements will be rejected without substantive review. ______________________________________________________________________________ Name of Organization ______________________________________________________________________________ Street Address ______________________________________________________________________________ City Zip/Postal Country Identify Organization Type: Constituent Member Associations of ANA College or University Healthcare Facility Health - Related Organization Multidisciplinary Educational Professional Nursing Education Group Specialty Nursing Organization Primary Point of Contact: Name and Credentials Title/Position ____________________________________________________________________________________ Telephone Number E-mail Address Has the applicant organization ever been denied accreditation by ANCC or had its accreditation status suspended or revoked? Yes No If yes, please provide the following information: Date: Action: Denial Suspension Revocation Brief description: Has the applicant organization ever been denied approval by or had approval suspended or revoked for an individual activity or a provider application by the Alabama State Nurses Association?
Alabama State Nurses Association Approved Provider Eligibility Verification Section 1: Demographic Data Organizations interested in submitting an application for approval as an Approved Provider must complete the Eligibility Verification and meet all Eligibility Requirements. Verification received from organizations that do not meet Eligibility Requirements will be rejected without substantive review. ______________________________________________________________________________ Name of Organization ______________________________________________________________________________ Street Address ______________________________________________________________________________ City Zip/Postal Country Identify Organization Type: Constituent Member Associations of ANA College or University Healthcare Facility Health - Related Organization Multidisciplinary Educational Professional Nursing Education Group Specialty Nursing Organization Primary Point of Contact: Name and Credentials Title/Position ____________________________________________________________________________________ Telephone Number E-mail Address Has the applicant organization ever been denied accreditation by ANCC or had its accreditation status suspended or revoked? Yes No If yes, please provide the following information: Date: Action: Denial Suspension Revocation Brief description: Has the applicant organization ever been denied approval by or had approval suspended or revoked for an individual activity or a provider application by the Alabama State Nurses Association?
Applicant_Eligibility_Verification_Individual_Activity_2014_Revision.docx