Application For Nurse Aide Certification Form printable pdf download

APPLICATION for NURSE AIDE CERTIFICATION

Name of applicant _________________________________________ Phone _____________________

Address ________________________________________________ SSN ______________________

________________________________________________ Date of birth ________________

E-mail address of applicant ______________________________________________________________

I am applying based upon my training as:

__ RN student/graduate

___ LPN student/graduate

__ military personnel

__ registered nurse

___ licensed practical nurse

Students-complete section I./Nurses-complete section II./Military personnel-complete section III.

(Provide all documentation listed in the section completed.)

*************************************************************************************

___

I. Name of School Attended (

_________________________________________________

if applicable)

Address of School _____________________________________________________________________

Included is:

__ a copy of my social security card

__ an official transcript

*********************************************************************************************

________________________________________________

II. Name of Licensing Board (

if applicable)

Address of Board ______________________________________________________________________

Included is:

__ a copy of my social security card

__ verification of my current status as a nurse

(

)

from Board

*********************************************************************************************

III. Branch of Military Where Trained (

_____________________________________________

if applicable)

a. Medical Training Received: ___________________________________________________

Included is:

__ a copy of my social security card

__ a DD-214

__ military transcript

*********************************************************************************************

NOTE: Any falsified documents submitted to this office will be forwarded to the Attorney General’s Office

for possible prosecution and your certification to the Louisiana Nurse Aide Registry will be revoked. All

required information (completed application and attachments) shall be submitted to:

Nurse Aide Training Program

DHH – Health Standards Section

P. O. Box 3767

Baton Rouge, La. 70821-3767

By virtue of my signature I agree that the information provided is true and correct. I will abide by all the state

regulations, federal regulations as well as Department of Health and Hospital policies and procedures. I understand

it is my responsibility to notify the Department of Health and Hospitals – Health Standards Section, in writing, of

any changes in the information provided at the time of application and to report any name changes, address changes

or telephone number or e-mail changes to the Louisiana Nurse Aide Registry once certified as a nurse aide. Failure

to do so may result in loss of nurse aide certification.

Print Name of Applicant______________________________________________ Title _______________________

Signature of Applicant _______________________________________________ Date _______________________

11-26-12

Application For Nurse Aide Certification Form

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