IN CO M PLETE APPLICATIO N S W ILL IN CUR DELAY AN D M AY N O T BE CO N SIDERED 1

IDENTIFICATION INFORMATION

NO FAXES ACCEPTEDNO STAPLES PLEASE

PLEASE PRINT LEGIBLY! All information must be accurate and complete to avoid delays. Please indicate your name as it appears on your certificate.

FIRST NAME MIDDLE INITIAL(S) LAST NAME

STREET ADDRESS R.R. NO. / P.O. BOX

CITY PROVINCE/TERRITORY POSTAL CODE

( ) ( )

HOME PHONE NUMBER OFFICE PHONE NUMBER PHONE EXTENSION

E-MAIL ADDRESS 1 E-MAIL ADDRESS 2

I am requesting inactive status because:

I do not meet the hours of nursing specialty experience

I do not meet the continuous learning activities criteriaand I am unable to write the exam

CNA Certification # ____ ____ ____ ____ ____ ____ ____ ____

Date of request ___________________________________

Language of correspondence preferred: English French

Cardiovascular CV

Community Health CM

Critical Care CC

Critical Care Pediatrics CP

Emergency ER

Enterostomal Therapy ET

Gastroenterology GI

Gerontology GR

Hospice Palliative Care PC

Medical-Surgical MS

Nephrology NP

Neuroscience NN

Occupational Health OH

Oncology OC

Orthopaedics OT

Perinatal PR

PeriAnesthesia PA

Perioperative OR

Psychiatric and Mental Health MH

Rehabilitation RH

Specialty Nursing Code:

All information is confidential.

GENERAL APPLICATION FORM FOR INACTIVE STATUS CANADIAN NURSES ASSOCIATION CERTIFICATION PROGRAM

Applications for inactive status must be sent before the specialty credential lapses.

Application form MUST be completed in full

IN CO M PLETE APPLICATIO N S W ILL IN CUR DELAY AN D M AY N O T BE CO N SIDERED 2

PLEASE EXPLAIN YOUR REASON(S)

FO R THE IN ACTIV E STATUS REQ UEST(ATTACH AD D ITIO N AL IN FO RM ATIO N AS N ECESSARY )

INACTIVE STATUS POLICY

Nurses who are unable to renew their CNA certification credential owing to personal or professional reasons mayrequest, before their certification expires, that their certification be declared inactive.

Inactive status provides nurses with an additional three years to meet their renewal requirements. However,eligibility requirements must be fulfilled within the five years before the date of status reactivation. Inactivestatus begins the day after the last day of the certification term. Certification status can be reactivated at any timeduring the three-year term as long as the candidate meets all of the renewal eligibility requirements in effect at thetime. If renewal requirements change during the period of inactivation, these must be met. The certificationcredential will be reactivated when the certification renewal application form and fee are submitted and theapplication has been approved.

Inactive status cannot be extended past one three-year term. The request for inactive status must be submitted toCNA before the certification expiry date. The candidate cannot use the CNA certification credential during theinactive period.

If a candidate does not apply for reactivated status before the end of the three-year inactive status term, thecertification credential will lapse. To earn the credential at a future date, the candidate will be required to meet all ofthe eligibility criteria in effect at that time and write the exam.

The fee for the inactive status application is $168 + GST/HST and is non-refundable.

If there are extenuating circumstances affecting reactivation, please contact the CNA Certification Program office todiscuss those circumstances before your three-year inactive status term ends.

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INACTIVE STATUS STATEMENT OF UNDERSTANDING

I understand that:

• My CNA certification status cannot remain inactive for longer than one three-year term.

• I cannot use the CNA certification credential during the inactive status period.

• I must comply with all of the CNA certification renewal eligibility requirements in effect at the time that I reapplyfor reactivation, and these requirements must be fulfilled within the five years before the date of reactivation.

• A non-refundable fee of $168 (+GST/HST) is required to apply for inactive status.

NAME (PLEASE PRINT)

SIGNATURE

DATE SPECIALTY CERTIFICATION

CERTIFICATION #

PLEASE K EEP A CO PY FO R Y O UR FILES.

PAYMENT METHODS

Cheque (enclose one cheque for full payment)

Credit card (complete the attached credit card payment form)

Money order (enclose one money order for full payment)

Cheques and money orders should be made

payable to the Canadian Nurses Associat ion.

INACTIVE STATUS APPLICATION FEE

Residents of PE: $168 + HST = $191.52

Residents of NS: $193.20 $168 + HST =

Residents of ON, NB, and NL: $189.84 $168 + HST =

$168 + GST =Residents of AB, BC, SK, MB,

$176.40 QC, NU, NT and YT:

IN CO M PLETE APPLICATIO N S W ILL IN CUR DELAY AN D M AY N O T BE CO N SIDERED 4

CNA CERTIFICATION PROGRAM PROCESSING CENTRE1400 Blair Place, Suite 210, Ottawa ON K1J 9B8 • 1-613-237-2133 • certification@cna-aiic.ca

getcertified.cna-aiic.ca

OFFICE USE ONLYDate received:_________________________________________________________________________________________________

Data entry: ___________________________________________________________________________________________________

Reviewed: Statement of Understanding

Payment

Approved by and date: __________________________________________________________________________________________

Valid until: ___________________________________________________________________________________________________

Revised May 2014

Send your application and payment to the CNA Certification ProgramProcessing Centre and contact the processing centre staff to discuss any questions about the processing of your application for inactive status.

All applications are to be sent to the processing centre.

Canadian Nurses AssociationCertification Program PROCESSING CENTRE

1400 Blair Place, Suite 210

Ottawa, ON K1J 9B8

Website: getcertified.cna-aiic.ca

E-mail: certification@cna-aiic.ca

Toll-free: 1-800-450-5206

Contact CNA certification staff to discuss professional issues about

certification renewal and inactive status.

Canadian Nurses AssociationCertification Program

50 DrivewayOttawa, ON K2P 1E2

Website: www.cna-aiic.ca

E-mail: certification@cna-aiic.ca

Toll-free: 1-800-361-8404