I attest, by my signature below, that I am duly authorized by {nameOf} to submit this application as an approved provider offered by the American Nurses Credentialing Center (ANCC) through Accredited Approvers and to make the statements herein. On behalf of {nameOf}, I have read the approved provider eligibility requirements and criteria. I understand that {nameOf} is subject to all eligibility requirements and criteria as an approved provider. I understand that becoming an approved provider depends on successfully meeting eligibility requirements and criteria and maintaining approved provider standing depends upon continued compliance.
On behalf of {nameOf}, I expressly acknowledge and agree that information accumulated through the approval process may be used for statistical, research, and evaluation purposes and that anonymous and aggregate data may be released to third parties. Otherwise, all information will be kept confidential and shall not be used for any other purposes without {nameOf}’s permission.
On behalf of {nameOf}, I hereby certify that the information provided on and with this application is true, complete, and correct. I further attest, by my signature on behalf of {nameOf}, that {nameOf} will comply with all eligibility requirements and approval criteria throughout the entire approval period, including all reapplication periods for maintaining approval, and that {nameOf} will notify the Virginia Nurses Association promptly if, for any reason while this application is pending or during any approval period, {nameOf} does not maintain compliance. I understand that any misstatement of material fact submitted on, with or in furtherance of this application for approved provider status shall be sufficient cause for the Virginia Nurses Association to deny, suspend or terminate {nameOf}’s approved provider status and to take other appropriate action against {nameOf}.
(Applications received without a signature incur a delay in processing which will cause a delay in the review of the approval application.)