Verification Of Pennsylvania Residency Form
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1
2VERIFICATION OF PENNSYLVANIA RESIDENCY
Please print legibly in ink
Date of Application ________________________ Proposed Date of NA Class Enrollment _____________________
Name _____________________________________________________________________________________
Provide an official photo identification showing a PA address. Verified by _____________________________________
Signature of an Authorized NATCEP Representative
YES
NO I have lived in Pennsylvania for at least 2 consecutive years prior to the date of NATCEP application.*
Current Pennsylvania Address __________________________________________________________________
Number of Months______Years______ at this Address
Telephone: (_______) _________________
*If you resided at your current PA address less than two years, record previous addresses and months and years of residency
on the back of this form. It is important that you record at least two (2) years of residency in Pennsylvania.
I understand that by submitting this completed form for Verification of Pennsylvania 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 to unsworn
falsification to authorities.
_________________________________________________________
__________________________________
Applicant’s Signature
Date
ATTESTATION OF COMPLIANCE WITH ACT 14
All candidates must submit an original or copy of an original PA CHRI obtained through the Pennsylvania State Police
during the year prior to enrolling in a PA NATCEP as required by Act 14. If a candidate has not been a resident of
Pennsylvania for the last two (2) consecutive years, a PA CHRI and an FBI report are required prior to enrollment.
As evidence that you have not been convicted of any of the Prohibitive Offenses Contained in 63 P.S. § 675, check the box
and sign and date the Attestation of Compliance with Act 14.
Candidates who were convicted of a Federal or out-of-State offense similar in nature to those crimes listed under
paragraphs (1) and (2) of the Prohibitive Offenses Contained in 63 P.S. § 675 must provide a PA CHRI and an FBI report
to determine eligibility for enrollment in a PA Nurse Aide Training Program.
Attestation of Compliance with Act 14
Nurse Aide Resident Abuse Prevention Training Act, 63 P.S. § 671 et seq.
This form represents my request to enroll in a nurse aide training program and verification of Compliance with Act 14 – Nurse
Aide Resident Abuse Prevention Training Act, 63 P.S. § 671 et seq.
I have reviewed the list of Prohibitive Offenses Contained in 63 P.S. § 675 and hereby testify that I have not been convicted of
any of the criminal offenses set forth in 63 P.S. §§ 675(a)(1)-(3).
(1) an offense designated as a felony under the act known as “The Controlled Substance, Drug, Device and Cosmetic Act”,
(2) an offense under one or more of the following provisions of Title 18, and
(3) a Federal or out-of-State offense similar in nature to those crimes listed under paragraphs (1) and (2).
By checking this box I state that I have not been convicted of any of the Prohibitive Offenses Contained in Act 14 of 1997
(set forth in 63 P.S. § 675 and found on the following page).
I understand that if I have been convicted of any of the criminal offenses set forth in 63 P.S. §§ 675(a)(1)-(3), it is possible that I
will not be eligible for employment in a long term care or other health care setting. A potential employer is also responsible for
reviewing my Criminal History Record Information report.
By signing this form, I certify under penalty of law that the information I have provided on this application is true,
correct and complete. I understand that false statements herein shall subject me to criminal prosecution under
18 Pa. C.S. § 4904, relating to unsworn falsification to authorities.
__ ________________________________________________
____________________________
Applicant’s Signature
Date
Revised 07/08/2014
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