State Form 49560 - Home Health Aide Registry Application Page 2
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2I, ________________, swear and affirm under the penalties of perjury that the foregoing is
true and accurate, and that I have read and understand 42 CFR 484.36 and have completed
a competency evaluation program as required by this regulation.
______________________________________
____________________
Home Health Aide’s Signature
Date
(month, day, year)
____________________________________
__________________
Program Director’s Signature
Date
(month, day, year)
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