Dermatology Certified Nurse Practitioner (DCNP) Application

If you are recertifying, this is not the right application. Please log into the website and complete the recertification application.

First NameMiddle NameLast NameMaiden Name
Last 4 Digits of SSNName on CertificateAddressCity
StateZipHome PhoneWork Phone
EmailPassword (minimum of 8 characters)GenderPreferred Pronouns
Birthdate
NP License (List State)Permanent NumberDate of Original LicenseExpiration Date
Additional State of LicensureAdditional State License NumberDate of Additional Original LicenseAdditional License Expiration Date
Years of Experience as NP in Dermatolgy Nursing
 Have you worked as an NP at least 3000 hours in dermatology nursing within the last 3 years?Check the appropriate practice setting(s) you have worked in during the past three years
 Outpatient Unit
 Physician's Private Practice
 Other (please specify)
Highest Level of Education Completed

Check the area of your clinical practice
 General Dermatology
 Dermatology Surgery
 Geriatrics
 Pediatrics
 Other (please specify)
 Are you currently certified in any other specialty? If yes, please list.
How did you become aware of the DCNP certification program? (check all that apply)
 DNPCB Website
 Linked-in
 Facebook
 Instagram
 SNDP Website
 SDNP Facebook
 DCNP Certification Application Brochure
 NPS Facebook
 Dermatology Conference
 Online Education
 Employer
 Fellow Dermatologist
 DNA Website
 DNA Focus Newsletter
 Dermatology Nursing Journal
 Educational activity other than conference
 Other
 Are you aware that DNPCB is accredited by the Accreditation Board for Specialty Nursing?
Employment History
Please list employment for the past 5 years beginning with present employment. Please do not send resumes.
Employer NameEmployer PhoneEmployer AddressEmployer CityEmployer StateEmployer Zip
Date From (Month/Year)Date To (Month/Year)Position title in clinical derm practice 
 Full Time
 Part Time
 Other (describe Below)
Employer NameEmployer PhoneEmployer AddressEmployer CityEmployer StateEmployer Zip
Date From (Month/Year)Date To (Month/Year)Position title in clinical derm practice 
 Full Time
 Part Time
 Other (describe Below)
Employer NameEmployer PhoneEmployer AddressEmployer CityEmployer StateEmployer Zip
Date From (Month/Year)Date To (Month/Year)Position title in clinical derm practice 
 Full Time
 Part Time
 Other (describe Below)
Employer NameEmployer PhoneEmployer AddressEmployer CityEmployer StateEmployer Zip
Date From (Month/Year)Date To (Month/Year)Position title in clinical derm practice 
 Full Time
 Part Time
 Other (describe Below)
Employer NameEmployer PhoneEmployer AddressEmployer CityEmployer StateEmployer Zip
Date From (Month/Year)Date To (Month/Year)Position title in clinical derm practice 
 Full Time
 Part Time
 Other (describe Below)
Upon successful completion of recertification, please notify my employer (optional)
NameTitle or PositionOrganizationEmail Address

Denial, Suspension, or Revocation of Certification. The occurrence of any of the following actions will result in the denial, suspension, or revocation of Dermatology Nurse Practitioner Certification: (1) falsification of the DNPCB application; (2) falsification of any material information requested by the DNPCB; (3) any restrictions such as revocation, suspension, probation, or other sanctions of professional NP license by nursing authority; (4) misrepresentation of DCNP status; (5) cheating on the DCNP examination.

STATEMENT OF UNDERSTANDING

I hereby attest that I have read and understand the DNPCB policy on Denial, Suspension, or Revocation of Certification and that its terms shall be binding on all applicants for certification and all certified dermatology nurses for the duration of their certification. I hereby apply for certification offered by the Dermatology Nurse Practitioner Certification Board. 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 purposes 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. 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 Dermatology Nurse Practitioner Certification Board reserves the right to verify any or all information on this application.

I also agree that my name and state may be published on the DNPCB website under "Find a DCNP" and may also appear on a congratulatory website banner.

Electronic Signature is acceptable.

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Type Your Full Name as Your SignatureSignature Date

Please Note: Visa, Mastercard and American Express are acceptable forms of payment. Discover Card is not accepted at this time.

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Dermatology Nurse Practitioner Certification Board
office@dnpcb.org