Certificate of Employment for Nurse Rn - PowerPoint by anl11563


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                                  New Mexico Department of Human Services
                              7600 Burnet Road - Suite 440, Austin, TX 78757-1292

Part A. Registration Information - must be filled out in its entirety or the application will be denied
PLEASE PRINT CLEARLY AND CAREFULLY: If address on this form is incorrect, you will have to pay a $15.00 fee to have a duplicate report sent
to your correct address.

 1. Social Security                                                               2. Birth Date:
        Number:                                                                                       month            day              year

 3. Print        Last

      Full       First                                                                                                       M.I.

      Name       Maiden

 4. Mailing Address
      PO Box
      State                                            Zip Code

 5. Daytime Telephone:
                                    area code

 6. Education Level: Write the code of your highest education level in this space:
              (01) 0-8 years of education              (03) high school diploma              (05) Associate Degree      (07) Other

              (02) 9-11 years of education             (04) GED                              (06) Bachelor’s Degree

 7. Agreement of Authorization and Confidentially
     I agree that the information in this application is correct and may be investigated by the New Mexico Department of Human Services. I
     understand that if I have given false information in this application, I may not be allowed to take the test and could be prosecuted by the State
     of New Mexico.
     Also, I understand that if I cheat or engage in other prohibited behavior during the test, I may be disqualified from continuing to take the test
     or from receiving my test results. I understand that test results will be sent to my approved training program where applicable. I understand
     that a record of the successful completion of this competency evaluation will be included in the New Mexico Registry. I understand that I
     must inform the registry of current employment information every 24 months or my record will be removed from the registry.
     I have read and understand the information in the New Mexico “Information Handbook for Nurse Aide Candidates”.
     Test Taker’s Signature _______________________________________________________ Date______________________________

 8. Release
     I do not have any physical, medical, or other condition that would be in any way affected by my participation in the Examination. I hereby
     release NACES, Promissor, the New Mexico Department of Human Services, and their agents and assigns from any responsibility or liability
     for any claim or damage that may result from my participation in the Examination.

     Test-Taker’s Signature _______________________________________________________ Date_____________________________

 9. Mailing Information
     Send completed documentation and fees( if appropriate) to NACES.Fees must either be a certified check or money order made payable to
     NACES. Completed documentation and fees must reach NACES 14 business day prior to scheduled test date. For assistance in completing
     the application, Call NACES at 1-800-477-6933 Monday through Friday 8:30 a.m. – 5 p.m. (Central Standard Time).

                                                             (continued on reverse side)
Part B. Training Verification - if applicable, this part is to be filled out in its entirety by the Program Director or the application will be denied
7. Training Program Code: T                                          Training Completion Date:

                                                                                                                     month      day        year
8. Program Director’s
       Social Security Number:

9. Name of Approved Training Program _________________________________________________________________________

10. Address: __________________________________________________________________________________________________
                        Street                                                  City                                               State          Zip Code
11. Phone                                                                       12. Fax
    Number:                                                                         Number:
                  area code                                                                        area code

Signature of Program Director: ____________________________________________Date:_________________________________

Part C. Eligibility - If applicable, this part is to be filled out in its entirety by applicant.

For Certification Routes 2, 3, 4, 5, and 6, nurse aide candidates must submit the original Approval Letter from the New Mexico
Department of Health along with the application form and fee (if appropriate) to NACES in order to be eligible to take the examination.
Check the appropriate eligibility route:

         1. New (New Mexico) Training Program Graduate                                        6. RN or LPN Student

         2. Military Trained                                                              7. Lapsed New Mexico Certificate
                                                                            New Mexico Certificate # NA/W
         3. Graduate RN LPN
         4. Out of State Nurse Aide (Lapsed)                                                  8. Lapsed new Mexico Certificate/Retrained

         5. Out of State/Foreign trained Nurse (RN/LPN)                    New Mexico Certificate # NA/W
                                                                                                                      (Attach Copy)
Part D. Work Verification - If you are employed (or have promise of employment) by a qualified nursing facility this part must be
filled out by the nursing facility Administrator or the application will be denied.
Date of Hire:                                                                   Medicaid Provider Code: I
                                                                                or Vendor #:

                        month         day           year

Name of Facility:________________________________________________________________________________________________________


City:_______________________________________________________________________State:___________Zip Code:____________________

I verify that this nurse aide is employed or has a promise of employment in this qualified nursing facility.

Administrator’s Signature _________________________________________________ Date_______________________

Part E. Exam Information – must be filled out completely or the application will be denied.

Type of Test: Check appropriate test

Skills & Written Exam $100.00                                     Skills Exam Retest $55.000                             Written Retest $45.00

Skills & Oral Exam $124.50                  English Oral         Spanish Oral                 Oral Retest $69.50         English Oral        Spanish Oral

REGIONAL TEST SITE:_____________________________________________________City:_________________________________________

CHOICE OF DATES               1._________________________            2.____________________________            3.____________________________

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