Maryland Insurance Administration - Department Of Health Page 2
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4G
D
C
OVERNMENT OF THE
ISTRICT OF
OLUMBIA
D
H
– H
R
& L
A
EPARTMENT OF
EALTH
EALTH
EGULATION
ICENSING
DMINISTRATION
APPLICATION FOR CERTIFICATION
SECTION 3B. HOME ADDRESS
P.O. BOX MAY NOT BE USED FOR AN ADDRESS. PLEASE PROVIDE A STREET ADDRESS.
This will be the address to which all future
documents related to your certification will be mailed.
ADDRESS:____________________________________________________________________________________________________________________
(Street Number and Street Name)
(City)
(State/Province/Territory)
(Zip Code)
APARTMENT #__________
PHONE NUMBER: (_____) ______ - ________
FAX: (______) ______ - ________
You are statutorily required to notify the DC Board of Nursing in writing of an address change within 30 days. Failure to do so may
result in your not receiving your certificate, renewal notice or other official notices and can result in a disciplinary action or a fine.
EMAIL ADDRESS (Please provide) : _______________________________________________ CELL PHONE: _______________________
SECTION 3C.
CURRENT EMPLOYER (s) (MANDATORY)
Name
Address
Hire Date
SECTION 3D.
CURRENT STATE CERTIFICATION AND PRACTICE (MANDATORY)
STATE
ACTIVE/
CERTIFICATION NUMBER (if
NOT ACTIVE
applicable)
SECTION 4.
FEES AND SUPPORTING DOCUMENTS
HOME HEALTH AIDE CERTIFICATION FEE:
$50.00
CRIMINAL BACKGROUND CHECK: -To schedule your live scan fingerprints visit
[now MorphoTrust] or
call 1-877-783-4187. For questions contact the CBC unit at 202-442-9004.
Please Note: You must submit this application
and obtain your certification number prior to registering for your fingerprint live scan. You can obtain your certification
number at
72 hours after your application has been submitted
.
Your application along with all required supporting documents must be mailed in the same package to the Board office. Please
mail in a 9X12 inch envelope and do not staple or fold application.
Passport-Type Photos - Two recent and identical passport-type photos of the applicant’s face (approx. 2”X2”) with
applicant's name printed on the back. The photos must be original photos and cannot be computer-generated copies or
paper copies.
Copy of legal document supporting name change (if applicable). Acceptable documents are marriage certificate, divorce
decree, court order or spouse’s death certificate.
SSN Affidavit Form (if no SSN issued) This document can be found at
Provide a detailed explanation if you answer “Yes” to any of the questions in Section 5. Submit copies of personnel action
(e.g. termination due to unsafe practice) actions taken against your license/certification or other relevant documents.
S
Home Health Aide Attestation Form to be completed by your employer and supervising nurse
SCREENING QUESTIONS
SECTION 6: REQUIRED SCREENING QUESTIONS CTION 6:
REQUIRED SCREENIN
UESTIONS
Page 2
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