Arizona State Board of Nursing
AFFIDAVIT RE: NURSING ASSISTANT TRAINING PROGRAM CHARGES FOR LONG
TERM CARE FACILITY BASED PROGRAMS ONLY
1. This form must be completed by Director of Nursing and/or Administrator of a facility-
based Nursing Assistant Training Program.
2. I certify that this facility’s Nursing Assistant Training Program will not charge students for
any portion of their course or for testing during or at the conclusion of the course.
AFFIDAVIT
The undersigned being duly sworn declares that he/she has read and understands this affidavit; understands that failure
to disclose the requested information or disclosure of false or misleading information may constitute fraud and may
result in denial of licensure/certification or disciplinary action, up to and including revocation, taken against an issued
certificate. Failure to disclose the requested information or disclosure of false or misleading information may also
result in criminal prosecution.
__________________________
Type or Print Your Name
JURAT
State of _________________________)
____________________________
Signature
County of_______________________)
_____________________________personally appeared before me, and under oath, swears that the statements made
(PRINTED NAME)
in this document and all attachments are true and correct this ____________ day of _________________, 20______
________________________________ ____________________________
NOTARY PUBLIC MY COMMISSION EXPIRES
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