Maryland Insurance Administration - Department Of Health
ADVERTISEMENT
1
2
3
4G
D
C
OVERNMENT OF THE
ISTRICT OF
OLUMBIA
D
H
EPARTMENT OF
EALTH
H
P
L
A
EALTH
ROFESSIONAL
ICENSING
DMINISTRATION
APPLICATION FOR ENDORSEMENT
BOARD OF NURSING
HOME HEALTH AIDE
All applicants must complete every section of this application and submit the original application and all required supporting documents. If more
space is needed to fully answer questions, attach additional sheets with typed responses. False or misleading statements will be cause for
disciplinary action and could be cause for criminal prosecution pursuant to DC Code 22-2514. If you have any questions, call HPLA Customer Service
at 1-877-672-2174 Monday through Friday, 8:30 AM to 4:30 PM EST.
Please Note: Please refer to application instructions before completing this form.
SECTION 1A. CERTIFICATION FEE
Home Health Aide Certification by Endorsement
CERTIFICATION EXPIRATION:
HHA Certificates expire October 30
2015
$50.00
th
CRIMINAL BACKGROUND CHECK:
For payment and to schedule
Make check or money order payable to:
an appointment call 1-877-783-4187 or visit )
DC Treasurer
All applicants are required to undergo a Criminal Background Check
SECTION 2A. APPLICANT INFORMATION
LEGAL NAME
:
(Do not use initials unless they are a part of your name)
_________________________________
______
_________________________________
________________________
FIRST NAME
MI
LAST NAME
(SUFFIX: Jr., Sr. etc.)
____/______/_____
__________ - ________ - _________
*
Date of Birth
Social Security Number
GENDER:
MALE
FEMALE
_______________________________________________________________________________________
______________________
Place of Birth: State/Providence/Territory
Country if not USA
*All applicants must provide a Social Security Number. If you are a foreign applicant and do not have a SSN or are waiting for one to be issued,
you must complete the SSN affidavit form and submit it with your application. Your certification will not be renewed without a valid SSN. You can
download the affidavit form by accessing it at
SECTION 2B. OTHER NAME USED: (Please print clearly)
If your name on this application is different from the name on your supporting documentation. Provide a copy of a legal name change
document. Acceptable documents for individuals are marriage certificates, divorce decrees, court orders and spouse’s death certificate.
__________________________________________
______
_____________________________________________
____________________
FIRST NAME
MI
LAST NAME
(SUFFIX: Jr., Sr. etc.)
SECTION 2C: RACE & ETHNICITY DESIGNATION:
LANGUAGE(S) SPOKEN:
Language(s) spoken other than
American Indian/Alaskan Native
Asian/South Asian
Black or African
English:
American
Spanish
French
Caucasian/White
Hispanic or Latino
German
Arabic
Other __________________
Native Hawaiian or other Pacific Islander
Other __________________
SECTION 3A. HOME HEALTH AIDE PROGRAM (MANDATORY)
Name of School
Address
Date Completed
Page 4
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Letters