National Council of Post-Acute Care Practitioners

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    A. Biography

    Full Name:

    Credentials (Example: RN, MSN):

    Home Address:

    Personal Email:
    Personal Phone:
    Work Email:
    Work Phone:

    Date of Birth: (YYYY-MM-DD)

    B. Education

    College / University:
    Year Graduated:
    Degree:

    College / University:
    Year Graduated:
    Degree:

    College / University:
    Year Graduated:
    Degree:

    C. Certification & License

    Nurses:

    License Number
    State
    Active?

    Other Health Care Professionals
    State
    Active?

    D. Employment (Nurses)
    Are you a self-employed consultant?
    total hours of consulting work per week

    Name of Organization/ Employer:
    Work Address:

    Length of Employment: to
    current position or title:

    Check One:

    Check One:

    E. Post-Acute Care Training/Work Experience (Nurses)

    Describe your current and past duties/experiences:

    Supervisor Name and Job Title:
    Supervisor email address:
    Supervisor Phone number:

    F. Employment (Other Health Care Professionals)

    Name of Organization/ Employer:
    Work Address:

    Length of Employment: to (YYYY-MM-DD)

    G. NCPACP Post-Acute Care Certified Staff Educator Seminar

    Date of Seminar (YYYY-MM-DD)
    Location: City/State
    Instructor Name
    Course Number

    H. Code of Ethics for PAC-CSE
    I have received, read and agree to abide by the NCPACP Code of Ethics for Post-Acute Care Certified Staff Educators. I attest with my signature below that I have retained copy of the code.

    Digital Signature
    Date (YYYY-MM-DD)