Arizona Nursing Assistant (Na) Examination Application
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1HEADMASTER LLP
D&S Diversified Technologies LLP
P.O. Box 6609, Helena, MT 59604-6609
Innovative, quality technology solutions
800-393-8664 – Fax: 406-442-3357
throughout the United States since 1985.
Headmaster LLP
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INSTRUCTIONS: (Also see )
DO NOT mail this NA Examination Application to the Arizona State Board of Nursing (AZBN).
1.
Complete this NA Examination Application. Completed paper applications must be received at HEADMASTER 8 business days prior to the testing day excluding
2.
Saturdays, Sundays & Holidays or express charges will occur.
Send this completed application with payment to P.O. Box 6609-Helena, MT 59604-6609.
3.
You must include proof of completion of an Arizona State Board of Nursing (AZBN) 120 hour approved NA training program and proof of employment as a NA if your NA
4.
training was completed more than 2 years ago OR include a Nursing Student/Military/Foreign Nursing Graduate Waiver Request form approved by the AZBN. (Available
from the Arizona Board or Nursing or at .)
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NOTE: Facilities MAKE ALL CHECKS PAYABLE TO HEADMASTER.
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Before submitting this testing application, please check off the following: (Incomplete applications will be returned to applicant for completion.)
This application is filled out completely and signed where required.
Exam payment is included with the testing application.
I have attached proof of my 120 hours of NA training to this application OR included a Nursing Student/Military/Foreign Nursing Graduate Waiver Request form approved by the AZBN.
(Form 1101)
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I
:
Print clearly (Use Ink) or Type
(High volume users on-line registration is available at )
ANDIDATE
NFORMATION
Social Security No.: ______ -_____ - ________
(Mandatory: Your Social Security number will only be shared with the Arizona State Board of Nursing)
Applicant’s Name________________________________________________________________________________________
Last
First
MI
Maiden/Former Name
Mailing Address__________________________________________________________________________________________
(P.O. Box # -or- Street number and name, including Apartment # - if applicable)
City___________________________________________________
State____________________
Zip__________________
Home Telephone________________________________ Message/Work Phone______________________________________
Birth Date (Month/Day/Year)____/____/______ E-Mail Address:___________________________________________________
(Mandatory)
Providing your email address is your authorization for us to use it for test confirmation and results letters.
I have successfully completed an AZBN approved 120 hour Nursing Assistant Training Program within the past 24 months OR I have completed an AZBN approved
training program more than 2 years ago and have attached proof of employment to show that I have performed nursing assistant duties during every 24 month period since
completing the training program OR I have attached a Nursing Student/Military/Foreign Nursing Graduate Waiver Request form approved by the AZBN.
Program Code #_______ Program Name_________________________
City________________________________
(On Certificate)
Date Completed_______________________ Contact Person______________________________________________________
If facility is paying for your test, this section must be completed by Nursing Supervisor
Facility Name_______________________________________________________ Phone_______________________________
Address_____________________________________________Contact Person_______________________________________
Signature of Nursing Supervisor______________________________________________ Date___________________________
The written test is also available orally. If you desire your written test to also include an audio reading place an X in this box.
I hereby declare that the above supplied information is true, complete, and accurate to the best of my knowledge. I hereby authorize release of my test results to my
5.
training program. I will honor my test appointment and agree to forfeit all test fees as payment for services provided if I do not show up for my test appointment. I will be
responsible for any cancellation, rescheduling, or dispute fees incurred as described in the Arizona candidate handbook. I also authorize a fax fee of $5.00 charged to my
credit card if I faxed my application into HEADMASTER. I also understand that if this is my first time testing that I must take both the knowledge and skill test. If this is a re-
take test I must re-test on the portion that I failed. I understand that if I paid by credit card that my credit card will be billed for both the knowledge and skill test or for the
portion of the test that I failed plus the fax fee (if applicable). PLEASE CALL 800-393-8664 IF YOU DO NOT RECEIVE AN E-MAIL OR REGULAR MAIL RESPONSE
WITHIN FIVE DAYS. *****NO PERSONAL CHECKS ACCEPTED.***** Complete paper applications must be received 8 business days prior to the testing day
(excluding Saturdays, Sundays & Holidays) or I understand and agree that express charges will be applied per candidate.
Candidate Signature____________________________________________________________________ _________________
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andidate MUST sign to verify acceptance (
)
Date
UNSIGNED APPLICATIONS WILL BE RETURNED
HEADMASTER/D&S DIVERSIFIED TECHNOLOGIES Form 1101AZ Arizona Nursing Assistant Examination Application
Updated: 12-1-2012
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