Renewal Application Nursing Assistant Instructor Form printable pdf download

Nevada State Board of

URSING

Renewal Application

Nursing Assistant Instructor

Return to: Nevada State Board of Nursing, 4220 S. Maryland Pkwy., #300, Las Vegas, NV 89119-7524

(702) 486-5800 or toll free (888) 590-6726, fax (702) 486-5803,

Last name: ___________________________________________ First name:__________________________________

Address: ________________________________________________________________________________________

City, State ZIP____________________________________________________________________________________

Email address: ___________________________________________________ SSN: ___________________________

Nevada RN License Number: __________________________ Instructor Number: _____________________________

Please note that the address furnished with this application will become your address of record unless you indicate

otherwise.

This renewal application, with the $100 renewal fee, must be received on or before the end of the business day on which

your current certificate expires, or your certificate will lapse.

To be eligible to renew your certificate, you must have taught at least one nursing assistant training program class within

the last two years. Please list each of the nursing assistant training programs you have taught within the last two years.

Name and location of training program

(please attach separate sheets, if necessary)

Date(s) taught

________________________________________________________________________________

_____________

________________________________________________________________________________

_____________

________________________________________________________________________________

_____________

________________________________________________________________________________

_____________

I hereby affirm (swear) that I:



hold a current, active Nevada nursing license in good standing;



have taught in a Board-approved Training Program for Nursing Assistants for compensation at least once in the

preceding two years; and



have used the Model Curriculum as a guide of competencies needed by nursing assistants caring for clients in a

variety of settings.

Signature _________________________________________________________________ Date __________________

The annual renewal fee is $100. You may pay by credit card (MasterCard, Discover, Visa), personal or cashier’s check,

or money order, made payable to the Nevada State Board of Nursing (NSBN). Remit U.S. Funds only.

Choose one: Visa____ MasterCard___ Discover___ Card number___________________________ Exp. date_____

Name on card__________________________________________________________________

Amount $100.00

Signature______________________________________________________________________________________

Renewal Application Nursing Assistant Instructor Form