Have you completed an approved nurse midwife educational program that is recognized by the American College of Nurse Midwives?
Yes
No
If yes, please identify the following:
Date educational program was successfully completed
Name of institution attended
2.
Licenses & Certificates:
Are you currently licensed as a Registered Nurse in the State of California?
Yes
No
If yes, please provide your license number below:
Do you possess a valid California Nurse Midwife Certificate?
Yes
No
If yes, please provide the certificate number:
3.
Do you acknowledge that you must possess a valid California Nurse Midwife furnishing number within one year of appointment to the class of Nurse Midwife?
Yes
No
4.
Experience:
Please use the space below to provide a detailed description of any existing Nurse Midwife experience that you possess. Include in your answer:
Dates of Employment
Job Title
Employer
Duties Performed
Note whether the experience was in a delivery or clinical non-delivery environment and/or whether you possess experience in both these areas
5.
Please use the space below to provide a detailed description of registered nursing experience that you possess in a Labor and Delivery Recovery and Post-Op environment. Include in your answer: