I hereby attest that I have read and understand the CBUNA policy on Denial, Suspension, or Revocation of Certification and that its terms shall be binding on all applicants for certification for the duration of their certification.

I hereby apply for certification offered by the Certification Board for Urologic Nurses and Associates. 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 analysis 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; however, upon passing the examination, CBUNA reserves the right to publish my name and certification expiration date by state on the CBUNA website.

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 Certification Board for Urologic Nurses and Associates reserves the right to verify any or all information on this application.