CNSW Certification Application

Page 1

Applicant Information

First Name

Last Name

Phone

Credentials

Facility

Job Title

State where you are licensed

State Lic/Cert #

Street Address

City

States

Zip/Postal Code

If approved, how would you like you name to appear on the certificate?

CV and Licensure Documentation

You may only upload files in Word, JPEG or Adobe Acrobat format where indicated.
File name should be no longer than 50 characters.
Files should be no larger than 50 megabytes.
File name should start with the first initial of your first name followed by your last name and then the name of the document (ie: NMarinoCV.doc).
To avoid difficulty in uploading your documents, please do not use spaces anywhere in the file name of your document.

Current resume/CV

Copy of current licensure/certification in the state(s) in which you are practicing.

Upload a copy of your licensure in (.pdf) or (.jpg) format. Only one upload is required.

License/Certification 1

License/Certification 2

License/Certification 3

Competency Summary Documentation

You will need to download, complete and save on your computer. Three completed forms will need to be uploaded with your application

Download (*PDF 43kb download)

We recommend upgrading to Adobe Reader 9 to enable the save form feature.

Two Summaries must be completed by nephrology social workers.
One Summary can be completed by a non-MSW, however that person must be employed within the field of nephrology (MD, RN, RD).
Note: Upon renewal of NSW-C Credential, selected applicants may be asked to provide competency summaries.
You may only upload files in Adobe Acrobat format.
File name should be no longer than 50 characters.
File name should start with the first initial of your first name followed by your last name and then the name of the document (ie: JDoeCOMP1.pdf).
To avoid difficulty in uploading your documents, please do not use spaces anywhere in the file name of your document.

Three Competency Summaries

Upload your completed Competency Summaries in (.pdf) format.

Competency Form 1

Competency Form 2

Competency Form 3

CEU Record Documentation

You will need to download, complete and save on your computer. The completed form will need to be uploaded with your application

Download (*PDF 32kb download)

We recommend upgrading to Adobe Reader 9 to enable the save form feature.

Applicants are required to show a total of 20 hours within a three year period. Ten hours must be nephrology related and three hours must be in ethics.
The online form provides areas to list Name of Activity and Type, Sponsoring Organization, Description of Content, Dates Attended and CEU Hours Earned.
You may only upload files in Adobe Acrobat format.
File name should be no longer than 50 characters.
File name should start with the first initial of your first name followed by your last name and then the name of the document (ie: JDoeCEURecord.pdf).
To avoid difficulty in uploading your documents, please do not use spaces anywhere in the file name of your document.

CEU Record Upload

Upload your completed CEU Record in (.pdf) format.

CEU Record

Discount

If you have a discount code, please enter it here.

Discount Code

CNSW Certification Payment

Payment Amount

Discount Amount

Total Amount

The credit card billing address is different than previous address given

Billing Address

First Name

Last Name

Address Line 1

Address Line 2

City

State/Province

Postal Code

Billing Email (note your receipt will be sent here)

Payment Information

Name on Card

Card Number

Code

Contact Information