Fillable Completion of Competency Evaluation and Skills Test Verication (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completion of Competency Evaluation and Skills Test Verication (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Completion of Competency Evaluation and Skills Test Verication
DearInitialApplicant:
The Records of the New Jersey Board of Nursing reveal that your Homemaker-Home HealthAide
Applicationhasbeeninactiveformorethanoneyear.Forthisreason,youmusttakethecompetencyevaluation
andskillstest.
Pleasehavethissectioncompletedandnotarized.Also,attachdocumentedprooffromtheagencythatyou
successfullycompletedthehomemakerhomehealthaidecompetencyevaluationandskillstest.
I certify that ____________________________has successfully repeated a Homemaker-Home Health
Aide competency evaluation and skills test on the ____________________day of _____________ at

___________________________________agency/school.
_________________________________________
Agency/SchoolOfcial’sSignature
Swornandsubscribedtomebeforethis____________
dayof_________________________,_____________
MonthYear
_____________________________________________
NameofNotaryPublic(pleaseprint)
______________________________________________________________________________
SignatureofNotaryPublic DateCommissionExpires
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Completion of Competency Evaluation and Skills Test Verication (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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