recertification renewal - International Nurses Society on Addictions

Name:Verification of Experience in Addictions NursingThe applicant must provide verification of a minimum of 2,000 hours (1 year) of addictions nursingexperience as a registered nurse in a staff, administrative, teaching, consultation, private practice,counseling, or research capacity. This experience must have occurred in the 4-year certification period.This form must be completed by the applicant’s supervisor(s). If necessary, please use additionalcopies of this from. Completed form(s) attesting to the 2000 hours of addictions nursing must be returnedwith the <strong>recertification</strong> application.I verify that(applicant) had experience in addictions nursingin the following capacity:From the following date to .Month/yearMonth/yearAverage number of hours per week:Name of practice setting:Address:City State / Province Country Zip codeSupervisor (Print name)Supervisor (Signature)Contact information:Telephone:Email:Address (if different from above):Address:City State / Province Country Zip codeDate:Revised July 2011