"Pennsylvania Nurse Aide Program Nnaap Registration Application for Reciprocity"

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Pennsylvania Nurse Aide Program
NNAAP
REGISTRATION APPLICATION FOR ENROLLMENT BY RECIPROCITY
®
PLEASE PRINT LEGIBLY — USE INK ONLY
This application must be completed by nurse aides requesting enrollment in the Pennsylvania Nurse Aide Registry.
PART I – APPLICANTS COMPLETE THIS SECTION
(Please type or print neatly in black ink)
APPLICANT MAILING INSTRUCTIONS
After you have completed PART I, forward this application to the state registry
where you are currently enrolled or it will be mailed back to you at the address indicated below.
A list of state nurse aide registries is available on Pearson VUE’s web page at www.pearsonvue.com/pa/nurseaides. Click the link for
Nurse Aide Registries (by state).
A. PERSONAL INFORMATION
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1 1 1
1 1
Social Security Number
Date of Birth
MONTH
DAY
YEAR
Please enter the last four digits of your Social Security number.
Current Legal Name: DO NOT USE NICKNAMES
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LAST
FIRST
MI
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MAIDEN NAME (if applicable)
Full Name as it Appears on the Registry (If different from above). Please provide proof of name change (ie. marriage certificate, court order).
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LAST
FIRST
MI
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MAIDEN NAME (if applicable)
Current Mailing Address
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STREET (number and name)
APARTMENT NUMBER
PO BOX
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CITY
STATE
ZIP CODE
Home
Work
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Phone Number
Phone Number
AREA CODE
AREA CODE
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Gender
Male
Female
B. CERTIFICATION INFORMATION: Your application will NOT be processed without this information.
State of
Registry
Expiration
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Certification
Number
Date
MONTH
DAY
YEAR
I certify that all the information provided on this application is true and complete. I give my permission to any state registry to
disclose all information requested on this application.
SIGNATURE OF APPLICANT
DATE
OUT OF STATE REGISTRY PERSONNEL: PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM.
Pennsylvania Nurse Aide Program
NNAAP
REGISTRATION APPLICATION FOR ENROLLMENT BY RECIPROCITY
®
PLEASE PRINT LEGIBLY — USE INK ONLY
This application must be completed by nurse aides requesting enrollment in the Pennsylvania Nurse Aide Registry.
PART I – APPLICANTS COMPLETE THIS SECTION
(Please type or print neatly in black ink)
APPLICANT MAILING INSTRUCTIONS
After you have completed PART I, forward this application to the state registry
where you are currently enrolled or it will be mailed back to you at the address indicated below.
A list of state nurse aide registries is available on Pearson VUE’s web page at www.pearsonvue.com/pa/nurseaides. Click the link for
Nurse Aide Registries (by state).
A. PERSONAL INFORMATION
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nn
nnnn
nn
nn
nnnn
-
-
-
-
1 1 1
1 1
Social Security Number
Date of Birth
MONTH
DAY
YEAR
Please enter the last four digits of your Social Security number.
Current Legal Name: DO NOT USE NICKNAMES
nnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnn n
LAST
FIRST
MI
nnnnnnnnnnnnnnnnnnn
MAIDEN NAME (if applicable)
Full Name as it Appears on the Registry (If different from above). Please provide proof of name change (ie. marriage certificate, court order).
nnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnn n
LAST
FIRST
MI
nnnnnnnnnnnnnnnnnnn
MAIDEN NAME (if applicable)
Current Mailing Address
nnnnnnnnnnnnnnnnnnnnnnnn nnnnnn nnnnnn
STREET (number and name)
APARTMENT NUMBER
PO BOX
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nn
nnnnn
CITY
STATE
ZIP CODE
Home
Work
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-
nnn
-
nnnn
nnn
-
nnn
-
nnnn
Phone Number
Phone Number
AREA CODE
AREA CODE
n
n
Gender
Male
Female
B. CERTIFICATION INFORMATION: Your application will NOT be processed without this information.
State of
Registry
Expiration
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nn
-
nn
-
nnnn
Certification
Number
Date
MONTH
DAY
YEAR
I certify that all the information provided on this application is true and complete. I give my permission to any state registry to
disclose all information requested on this application.
SIGNATURE OF APPLICANT
DATE
OUT OF STATE REGISTRY PERSONNEL: PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM.
PART II – REGISTRY PERSONNEL COMPLETE THIS SECTION
(in the state where the applicant is currently listed)
REGISTRY MAILING INSTRUCTIONS
After you have completed PART II, mail this application to:
Pearson VUE – Pennsylvania Nurse Aide Registry, PO Box 13785, Philadelphia, PA 19101-3785.
Has the above mentioned individual been enrolled on your nurse aide registry by meeting one of the enrollment requirements
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as mandated by the OBRA regulations?
Yes
No
If Yes, by which method
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Certificate Number
Expiration Date
MONTH
DAY
YEAR
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Is this certificate current and in good standing?
Yes
No
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-
-
Date this individual was enrolled on your registry
MONTH
DAY
YEAR
Are there documented findings on the nurse aide registry of resident abuse, neglect or misappropriation of property for this
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applicant? If "Yes", please list below:
Yes
No
Print name of official completing this form
SIGNATURE
TITLE
AGENCY
STATE
DATE
Copyright © 2015 Pearson Education, Inc., or its affiliates. All Rights Reserved.
Stock # 0639-09 3/10 rev
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