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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/