PAC-CSE Application

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)

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