Pathway Online Application Form

Please return the completed form and send your non-refundable application fee. Fee applies to both new application and re-designation applications, payable to "ANCC." Send all checks to: AMERICAN NURSES CREDENTIALING CENTER PO BOX 79120 BALTIMORE, MD 21279-0129

SECTION A *denotes required fields

Type of Application* Initial Redesignation

Name of Applicant Health Care Organization*

Street Address (PO Box not accepted)*

Street Address Line 2

City*	State *	Zip*

*Document Submission Date:**

*Is the applicant health care part of a system? If Yes, provide name of the system.** Yes No

Name


SECTION B

General population focus:
Acute Care	Ambulatory Care
Home Care	Hospice
Long Term Care	Critical Access
Other

Sub-specialty focus, if any:
Cardiac	Oncology
Pediatric	Psychiatric
Pulmonary	Rehabilitation

*Number of Licensed Beds: Average daily census:*


SECTION C

CNO Full Name and Credentials*

BSN* MSN/MN* PhD/DNSc* *A bachelor's degree or higher in nursing* is required.**

Other Degrees

Certifications

Position Title*

Phone*	Fax*	Email Address*

Assistant Name

Assistant's Email

SECTION D
Pathway to Excellence Point of Contact Name and Credentials*

Phone *	Fax*	Email Address*

SECTION E
Please submit all the following documents as attachments to PATHWAYINFO@ANA.ORG: The Chief Nursing Officer's curriculum vitae or resume. A current facility Organizational Chart that reflects CNO's and nursing's relationship to the entire facility.

SECTION F
An "X" next to the Chief Nursing Officer's agreement block below indicates that the Chief Nursing Officer has reviewed, understands, and is in compliance with all the Pathway to Excellence Recognition Program's eligibility requirements as indicated in the 2009 manual. The Chief Nursing Officer has also reviewed and understands the Pathway to Excellence Recognition Program review process and non-refundable fee structure. Chief Nursing Officer Agreement* Date*

Please return the completed form and send your non-refundable application fee. Fee applies to both new application and re-designation applications, payable to "ANCC." Send all checks to: AMERICAN NURSES CREDENTIALING CENTER PO BOX 79120 BALTIMORE, MD 21279-0129

From:
Email:
To:
Email:
Subject:
Message:

I Want To...

Events