Paper Appeals Form[1] - cnlcp.org · Appeals!Form! Full$Name:$_____$ Email$Address:$_____$...

Appeals  Form  

Full  Name:  _________________________________________________________________________  Email  Address:  ______________________________________________________________________  

Address:  ___________________________________________________________________________  

___________________________________________________________________________________  

Primary  Phone:  __________________________                        Secondary  Phone:  ________________________  

I’m  appealing:   ☐  Exam  Eligibility     Exam  Date:  ____/____/_____  

    ☐  Exam  Results  

My  appeal:    Clearly  state  the  basis  for  your  appeal  and  include  any  supporting  information.  Please  attached  a  separate  sheet  if  necessary.      

Internal  Use  Date  Received:  __________  By:  ________  Response  Mailed:  _________  By:  _______  

CNLCP®  PO  Box  3311  Concord,  NH  03302-­‐3311  Tel.  (626)  303-­‐6333,  Ext.  216  

The  CNLCP®  Certification  Board  will  respond,  in  writing,  within  60  days  of  receipt  of  the  appeal  request.  The  decision  of  the  CNLCP®  Certification  Board  is  final.    

The  appeal  must  be  made  in  writing  via  certified  letter/US  Postal  Service,  fax  or  online.    By  Mail:    Jan  Roughan,  RN,  CNLCP    CNLCP®  Certification  Board  Chair      114  W.  Colorado  Blvd.  Monrovia,  CA  91016  Telephone:  (626)  303-­‐6333,  Ext.  216    Fax:  (626)  303-­‐8080    Online:    Visit  us  at  www.cnlcp.org/appeals/