Form Doh 667-034 - Nursing Assistant Expired Certification Activation Application (Page 7 of 9) in pdf

Form Doh 667-034 - Nursing Assistant Expired Certification Activation Application Page 7

6. Continuing Education/Continuing Competency Attestation

(if applicable)

I certify that I have met all continuing education and continuing competency requirements for the past two years.

I am enclosing documentation on all classes attended/claimed.

Applicant’s Initials

Date

7. Applicant’s Attestation

I, ________________________________ , declare under penalty of perjury under the laws of the state of

(Print applicant name clearly)

Washington that the following is true and correct:

•

I am the person described and identified in this application.

•

I have read

RCW 18.130.170

and

RCW 18.130.180

of the Uniform Disciplinary Act.

•

I have answered all questions truthfully and completely.

•

The documentation provided in support of my application is accurate to the best of my

knowledge.

•

I have read all laws and rules related to my profession.

I understand the Department of Health may require more information before deciding on my application. The

department may independently check conviction records with state or federal databases.

I authorize the release of any files or records the department requires to process this application. This

includes information from all hospitals, educational or other organizations, my references, and past and present

employers and business and professional associates. It also includes information from federal, state, local or

foreign government agencies.

I understand that I must inform the department of any past, current or future criminal charges or

convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability

to provide quality health care. If requested, I will authorize my health providers to release to the department

information on my health, including mental health and any substance abuse treatment.

Dated ______________________________By: ______________________________________________

(mm/dd/yyyy)

(Original Signature of Applicant)

DOH 667-034 September 2016

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Form Doh 667-034 - Nursing Assistant Expired Certification Activation Application Page 7