Get the free texas cna reciprocity 2014 form

of this form and mail completed form to: Texas Department of Aging and Disability Services P.O. Box 244840 Austin, Texas 78713-2448 40-082-3500 Fax: 281-931-2223 I. I certify that (i) as of December 1, 1998 my name (or the family member's as appropriate), date of birth, driver's license number, Social Security number, U.S. passport number, as well as any contact information such as telephone numbers, mailing addresses, and email addresses were accurate and current as of that date (or I am a successor to name as set forth above which was not inaccurate and current); (ii) I have completed one of the following: (A) My signature (the individual signing this form will only attest to the validity of my signature if his signature is dated as of the dates listed) "I certify that this application form is true and accurate as of the date and time below" (B) My signature (the individual signing this form will only attest to the validity of my signature if his signature is dated as of the dates listed) I agree to enter this information for all parties to be entered into the registry as of the information given in this application and I agree that under penalty of perjury that, if requested, I will supply a photocopy of the signed and dated Application for Registration as a Nurse Assistant, completed as of December 1, 1998. I further certify that I fully understand the scope of the information listed below as well as the conditions under which the signatory would be willing to enter my name or any information required on this form into the registry. II. I certify [name] was a nurse aide who is now deceased from any cause (please state the reason), was at the time of death aged 65 years or older, and had served in the employ of the Texas Department of Aging and Disability Services for at least 5 years. III. I certify [name] was a nurse aide who is now deceased from any cause (please state the reason), was at the time of death aged 65 years or older, and had served in the employ of the Texas Department of Aging and Disability Services for at least 5 years. IV. [name] was licensed as a nurse aide in Texas in accordance with the Texas Nursing Aide Act by the Texas Department of Licensing and Regulation, Division of Nursing; [surname] at the time of license shall be used to identify this individual. V. I hereby

Form 5505-NAR, Request for Entry on the Texas Nurse Aide Registry Through Reciprocity.