D&S Diversified Technologies LLP
Headmaster LLP
HEADMASTER LLP
P.O. Box 6609, Helena, MT 59604-6609
625 Barney, Suite A, Helena, MT 59602
800-393-8664 – Fax: 406-442-3357 / www.hdmaster.com
Email: hdmaster@hdmaster.com
Innovative, quality technology solutions
throughout the United States since 1985.
HEADMASTER (Form 1500OR) Updated: 06-01-2018
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(PLEASE TYPE OR PRINT AND ATTACH AN UPDATED RESUME AND A COPY OF YOUR RN NURSING LICENSE)
Pe
rsonal Information: (Please type or print)
Social Security #_______________-_________-__________________
Name:_________________________________________ _______________________________________________ _________________
(Last) (First) (Middle Initial)
Address:____________________________________________________________ | ____________________________________________
(Street Address including Apartment #) (E-Mail Address)
____________________________________________________ _________________________ __________________________
(City) (State) (Zip Code)
Date of Birth: / /
(Month) (Day) (Year)
Sex: Male Female
(Please check one)
Nurse Affidavit:
I am a registered nurse with an unencumbered OREGON nursing license: Registry # __________________________ and I have at least two year's
experience in providing long term care for the elderly or the chronically ill of any age:
Work Experience Verification:_________________________________________________ Phone:______________________________
(Supervisor)
Facility Name:__________________________Address:_______________________________ will verify my two year's work experience in a
long term care facility.
Work Expectations:
I will administer HEADMASTER nursing assistant written/oral and/or skill tests at a HEADMASTER approved testing sites that meet Oregon State
Board of Nursing and HEADMASTER requirements. In addition, I will insure that all necessary materials and equipment are available for the
consistent administration of the HEADMASTER nursing assistant written/oral and/or skill tests as listed on form 1503OR. I will not administer tests to
nursing assistant candidates with whom I have a prior personal or business association or to my own students, family or close personal friends. I also
understand that any person I use as an actor or WTP will not be eligible to take the test to become a nursing assistant in Oregon for twelve months
from the last date they worked as an actor or written test proctor.
Verification:
I hereby verify that the above information is true and correct and I understand and will abide by all terms and conditions agreed to:
_________________________________________________________ ____/_______/_________
(Applicant Signature) (Date)
Reference:
I certify that the applicant is known to me and the information listed above is true and correct to the best of my knowledge.
_______________________________________________ / ________________________________________________________________
(Reference Signature) (Address)
Reference's Title: _________________________________________________ Phone #:________________________________________
******************************************************************************************************
*************************************************************
HEADMASTER use ONLY: Observer ID # assigned: __________________ on _________________________by______________________________
(HEADMASTER official)
NURSING LICENSE VERIFICATION: DATE__________________ EXPIRATION DATE __________________ OTHER________________
*********************************************************************************************************************************************************************************************************************************
OSBN use ONLY: Approved by __________________________________________________________ on ____________/_________/____________
