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: NPRNLPNLVNOther License Number State Active? YesNo Other Health Care Professionals State Active? YesNo D. Employment (Nurses) Are you a self-employed consultant? YesNo total hours of consulting work per week Name of Organization/ Employer: Work Address: Length of Employment: to current position or title: Check One: Full timePart TimeVolunteer Check One: Assisted LivingNursing HomeCCRCHospitalAdult Day CareHospiceHome Care AgencyRetirement HomeManagement CompanyGovernment AgencyRehab CenterPhysician/ NP OfficePharmacy CompanyDietitian CompanyPrivate PracticeAssociationPrivate ConsultantUniversityTrade SchoolOther 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) Trainer/ Educator for Trade SchoolCollege/UniversityCorporate TrainerOwnerCEOPresidentCOOVice PresidentRegional PositionExecutive DirectoAdministratorMedical DirectorLicensed PharmacistsOther 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) Δ