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COMMONWEALTH BOARD OF NURSE EXAMINERS

P. O. Box 501458, CK
Saipan, MP 96950
Telephone: (670) 233-CBNE (2263)
Email: cbone@pticom.com

CERTIFICATION OF RELATED LEARNING EXPERIENCE


NAME: ________________________________________________________________
NAME OF COLLEGE
OR UNIVERSITY ATTENDED: ______________________________________________
DEGREE OBTAINED: _____________________________________________________
DATE OF GRADUATION: __________________________________________________

BREAKDOWN OF CLINICAL NURSING PRACTICE EXPERIENCE, AS


STIPULATED IN NURSING COURSES:
CLINICAL PRACTICE

SUBJECT AREA

(how many hours in a


week x how many
weeks)

MEDICAL NURSING

SURGICAL NURSING

PEDIATRIC NURSING

OBSTETRIC NURSING

PSYCHIATRIC NURSING

Certified By: _________________________________

TOTAL CLINICAL
PRACTICE
EXPERIENCE
(show in hours & weeks)

Registrar or Dean of College of University


Here)
Date: _______________________________________
CBNE Doc 47

(Affix Official Seal

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