Submit Your Application As Early As Possible with the Appropriate Fee, Made Payable to CBUNA

RECERTIFICATION APPLICATION

To complete the recertification application online or to download this form, go to www.cbuna.org, “In This Section”, then click on Recertification

Name: Name as it is to appear on certificate: Home Address: City: State: Zip: Phone: Work ( ) - Home ( ) - Email address: Work Home: Current Certification: Advanced Practice (NP, CNS, PA) RN Associate (LPN, LVN, Technician) Date of last certification (from wallet card): / / License (if applicable): State: Permanent number: Expiration date: / /

Practice Experience Employer/Institution: Business Address: City: State: Zip: Date Employment Began: / / Title or Position Held: Brief Urologic Job Description: I meet the following eligibility requirements for certification renewal by continuing education: 1. current licensure (if applicable) 2. current certification by CBUNA 3. minimum of 800 hours of urologic practice experience during the previous 3-year certification period

I hereby attest that I have read and understand the CBUNA policy on Denial, Suspension, or Revocation of Certification and that its terms shall be binding on all applicants for certification for the duration of their certification.

I hereby apply for certification offered by the Certification Board for Urologic Nurses and Associates. I understand that certification depends upon successful completion of the specified requirements. I further understand that the information accrued in the certification process may be used for statistical analysis and for evaluation of the certification program. I further understand that the information from my certification records shall be held in confidence and shall not be used for any other purpose without my permission; however, upon passing the examination, CBUNA reserves the right to publish my name and certification expiration date by state on the CBUNA website.

To the best of my knowledge, the information contained in this application is true, complete, correct, and is made in good faith. I understand that the Certification Board for Urologic Nurses and Associates reserves the right to verify any or all information on this application.

Signature: Date: / /

Method of Payment

SUNA Member: CUA/CURN $150.00 Nonmember: CUA/CURN $225.00

SUNA Member: CUNP/CUCNS/CUPA $175.00 Nonmember: CUNP/CUCNS/CUPA $250.00

Grace period/late fee (January 1 – March 31) $50 Method of Payment: Check or Credit Card Master Card Visa Amex Credit Card # Expiry Date: Card Security code: 3 digit code/back of MC/Visa or 4 digit code/front of American Express Cardholders Name: Signature: Billing Address: City: State: Zip:

Submit your application as early as possible with the appropriate fee, made payable to CBUNA. Processing requires 6-8 weeks. It is suggested that all materials be mailed certified, return receipt requested to: Fed Ex/UPS mail: CBUNA, 200 East Holly Ave., Sewell, NJ 08080 USPS: CBUNA, East Holly Ave. Box 56, Pitman, NJ 08071 *CATEGORY A: UROLOGIC HEALTH CARE Please type Photo copy this form if additional space is needed. If you have listed 50 or more contact hours in Category A (Urologic Programs) you do not need to complete Category B (General Nursing Programs). "The Recertification Process" booklet is available online at www.cbuna.org for the most current list of accepted contact hour sources

(1) (2) (3) (4) (5) (6) (7) (8) Date of Activity Activity Title (chronological Activity Sponsor Accredited Provider Location Type of Number of Office order) or Provider # (City and State) Contact Approved Use hours* Contact Hours Only

*Type of Contact Hour: Name: A = Author Total contact hours this page: CME = Continuing Medical Education Grand total of all Category A pages: Minimum 36 Contact Hours* CNE = Continuing Nursing Education E = Editor H = Home Study M = Meeting Attendee S/P = Speaker/presenter O = Other *CATEGORY B: GENERAL NURSING, HEALTH CARE & ACADEMIC Please type Photocopy this form if additional space is needed. "The Recertification Process" booklet is available online at www.cbuna.org for the most current list of accepted contact hour sources

(1) (2) (3) (4) (5) (6) (7) (8)

Activity Title Date of Activity Activity Sponsor Accredited Provider Location Type of Number of Office (chronological or Provider # (City and State) Contact Approved Use order) hours* Contact Hours Only

Name: *Contact Hour Codes: Total contact hours this page: A = Author AQH = Academic Quarter Hour Grand total of all Category B pages: Maximum 14 Contact Hours* ASH = Academic Quarter Semester CME = Continuing Medical Education CNE = Continuing Nursing Education H = Home Study M = Meeting Attendee S/P = Speaker/presenter