Verification Of Pa Residency printable pdf download

VERIFICATION OF PA RESIDENCY

Please type or print legibly in ink.

Date of Application ___________________________ Proposed Date of N.A. Class Enrollment ________________

Personal Information

A) Name: ____________________________________________________________________________

B) Current Address: ____________________________________________________________________

_____________________________________________________________________________________

City

State

Zip Code

C) Months/Years at this Address: _______________________ D) Telephone: ______________________

If you have resided at your current address for less than two years:

Previous Address:

_____________________________________________________________________________________

City

State

Zip Code

Months/Years at this Address_______________________

*If necessary, attach a list of other places of residence to demonstrate that you have lived in Pennsylvania for the past two

(2) years.

II. Forms of Identification – must be verified by program representative

A) Birth Date: Month/Day/Year __ __ / __ __ / __ __ __ __

B) Please provide two (2) additional forms of official, signature-bearing identification (one of which mustbe a current

photo identification document). Examples of proper identification include:

• Driver’s License

• Clinic card • Credit card

• State-issued identification card

• Passport

• Library card

• Alien registration card • Other ________________

III. Education

A) Do you have a high school diploma or GED? Yes No

B) Name of high school:

__________________________________________________________________________________________________

________________________________________________________________________

Address City & State Dates Attended Date of Graduation

C) Did you attend an educational institution beyond high school? Yes No

If yes, enter the name of the school (s): _____________________________________________________

IV. Nurse Aide Signature

I understand that by submitting this completed form for Verification of PA Residency to enroll in a nurse aide training

program, I am certifying that all of the information I have provided on this application is complete, accurate, true and

correct. I make this declaration subject to the penalties of 18 PA.C.S 4904 relating tounsworn falsification to authorities.

Signature: ___________________________________________________ Date: __________________

Verification Of Pa Residency