It Is Suggested That All Materials Be Mailed Certified, Return Receipt Requested To

To complete the recertification application online or to download this form, go to “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: //
Upon successful completion of the recertification process, I would like a letter sent to my employer. To the attention of:
Practice Experience
Employer/Institution:
Business Address:
City: / State: / Zip:
Date Employment Began: //
Title or Position Held:
Brief 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 recertification information provided in this application booklet. I hereby apply for renewal of certification and verify all information is correct.
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:

Update 5/12

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 50 or more contact hours in Category A (Urologic Programs) you need not complete Form B (General Nursing Programs).

"The Recertification Process" is available online at for the most current list of accepted contact hour sources

(1)
Activity Title / (2)
Date of Activity
(chronological
order) / (3)
Activity Sponsor / (4)
Accredited Provider or Provider # / (5)
Location
(City and State) / (6)
Type of Contact hours* / (7)
Number of
Approved
Contact Hours / (8)
Office
Use
Only
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Name:
Total contact hours this page:
Category A = Minimum 36 Contact Hours

CATEGORY B: GENERAL NURSING, HEALTH CARE & ACADEMIC

Please type

Photocopy this form if additional space is needed.

"The Recertification Process" is available online at for the most current list of accepted contact hour sources