Fillable Form 1: D E F N C A (North Dakota State College of Science)

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Form 1: D E F N C A (North Dakota State College of Science)

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  • 22 check-boxes
  • 36 other fields

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D&S Diversified Technologies LLP
Headmaster LLP
HEADMASTER LLP
P.O. Box 6609, Helena, MT 59604-6609
800-393-8664 – Fax: 406-442-3357
www.hdmaster.com
Innovative, quality technology solutions
throughout the United States since 1985.
FORM 1101ND - Updated: 1/1/2012 Page 1
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)
CANDIDATE INFORMATION (PLEASE PRINT)
Social Security Number ___________-__________-___________ Email _______________________________________
Last___________________________________First____________________________ Middle_____________________
Address _______________________________________City __________________ State __________Zip ___________
Home Telephone (________) __________-__________ Date of Birth ________/________/_________
If you are requesting an oral version of the Written Test, please write oral on this line _________. Oral includes a cassette
tape on which questions are read out loud. There is an additional fee for an oral Written test. See form 1402ND. The Oral
test comes in English only.
OPTIONAL SURVEY QUESTIONS
Gender: Male Female
Race: Asian Black Hispanic Native American Caucasian Other __________________
TRAINING INFORMATION
I have not been enrolled in a NDDH approved training program during the last two years. I am challenging the
test without training.
I have been enrolled in and completed the following NDDH approved training program during the last two years.
Please include a copy of your training certificate. Incomplete training program information will be considered a
CHALLENGE.
Training Program ______________________________________________ Completion Date ________/________/__________ Training Hours ___________
Address ______________________________________________________ City ____________________________ State ___________ ZIP ______________
Phone Number ___________________________________________ Contact Person _______________________________________________
LIST YOUR NURSING ASSISTANT EMPLOYERS STARTING WITH CURRENT OR MOST RECENT
FACILITY NAME LOCATION FROM TO
_____________________________________ _______________________________ __________ __________
_____________________________________ _______________________________ __________ __________
_____________________________________ _______________________________ __________ __________
D&S Diversified Technologies LLP
Headmaster LLP
HEADMASTER LLP
P.O. Box 6609, Helena, MT 59604-6609
800-393-8664 – Fax: 406-442-3357
www.hdmaster.com
Innovative, quality technology solutions
throughout the United States since 1985.
FORM 1101ND - Updated: 1/1/2012 Page 2
ALL QUESTIONS MUST BE COMPLETED
The fact that an arrest, conviction, plea, or adjudication occurred as a juvenile or through juvenile court authorities, or has
previously been pardoned, expunged, dismissed, or that your civil rights have been restored, does not mean that you can
answer question #1 and question #2 "NO".
Yes
No
1. Have you ever been arrested, charged, or convicted of a crime other than a minor traffic
offense?
2. Has any court deferred imposition of a sentence, suspension of a sentence, or have you
entered a plea of nolo contendere to any crime in any jurisdiction?
3. Have you ever had a nurse aide registry listing marked for abuse, neglect or
misappropriation of property?
4. Has your registration or nursing license ever been suspended, revoked, encumbered or
otherwise sanctioned?
5. Have you been investigated by any other jurisdiction?
6. Have you ever been denied registration or nursing licensure by any other state?
If your answer is "YES" to any of the above questions, please write below a detailed written explanation (dates, places,
charges, and results). Include any legal documents and send them with this application. If you are under eighteen please
have your parent or guardian sign this NA application.
CANDIDATE MUST SIGN AND DATE
Signing below, verifies that all information provided to HEADMASTER is true and accurate and verifies that you are
physically able to perform the tasks that you may be asked to perform during the clinical skill demonstration portion of the
Nurse Aide Competency Exam and further, that you are NOT under Doctor’s Orders and will inform HEADMASTER
immediately if you come under a Doctor’s Order and can’t perform skill tasks that a Nurse Aide must perform to take the
Certification Test or perform the regular duties of a Nurse Aide.
I certify the information on this document is true and correct:
Candidate Signature: ________________________________________________ Date: _______/________/_________
Printed Candidate Name: ____________________________________________________________________________
Parent or Guardian Signature (If you are under eighteen): __________________________________________________
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Form 1: D E F N C A (North Dakota State College of Science)

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Completed 26 July 2020

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