Fillable form and supporting documentation must be submitted by (Vance-Granville Community College)

Fill Online, Printable, Fillable, Blank form and supporting documentation must be submitted by (Vance-Granville Community College) Form

Use Fill to complete blank online VANCE-GRANVILLE COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

form and supporting documentation must be submitted by (Vance-Granville Community College)

On average this form takes 6 minutes to complete

The form and supporting documentation must be submitted by (Vance-Granville Community College) form is 2 pages long and contains:

  • 1 signature
  • 2 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Vance-Granville Community College

BROWSE VANCE-GRANVILLE COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Nursing Programs Waiver Request Form CNAI
Requirement
Directions: Students requesting a waiver of the CNAI requirement must complete this form and submit all
related supporting documentation for review by the Nursing Department Admissions Committee. The
form and supporting documentation must be submitted by the PROGRAM APPLICATION deadline for
ADN and PN admission. Early submission is encouraged as recommendations may be sent from the
committee for completion by the applicant.
Student Name: Student ID #
VGCC Student Email Address:
Date Submitted: Program of Study:
Waiver Requested for (Please check one):
□ CNAI Registry Listing
Approved Substitutions for CNAI Requirement (pending verification of documentation):
1. Current unrestricted North Carolina LPN license (verified at www.ncbon.com)
NC LPN License Number:
Date verified: By:
2. Current status as a Certified or Registered Medical Assistant via one of the following avenues:
- American Medical
Technologists
http://www.americanmedtech.org/Certification/MedicalAssistant.aspx
- The American Registry of Medical Assistants
http://www.arma-cert.org/
- American Association of Medical Assistants
http://www.aama-ntl.org/
Current c
ard verifying certification or registry must be submitted by the student.
Agency: Card Number: Expiration Date:
Please note: a degree or diploma as a medical assistant is NOT accepted. The student must be certified or
registered via one of the avenues as listed above.
3. Current licensure as NC EMT-Paramedic
Card Number: Expiration Date:
Rev. 3/23/2020
Student Name: Student ID #:
Work Verification (To be completed by supervisor at place of employment)
□ Student meets qualification of 640 hours of full or part time employment in occupation related to
waiver request.
1. Place of employment (name, address, phone number):
2. Description of place of employment:
3. Months employed as full time or hours worked as a part time employee:
By signing below, I indicate that the above listed employee has been employed at the facility for the number
of months or hours listed above.
Printed Name of Supervisor and Title Signature of Supervisor Date
All other certifications, work-related experiences or educational experiences will need to be submitted for
review by the committee. Please send all documentation such as certification certificates, registry listings,
employment verification (including job description and hours worked), and/or schooling information by the
PROGRAM APPLICATION DEADLINE for ADN and PN admission.
This form should be submitted with the PROGRAM APPLICATION by the deadline.
Rev. 3/23/2020
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

form and supporting documentation must be submitted by (Vance-Granville Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 September 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document