South Carolina Nurse Aide Program
NATIONAL NURSE AIDE ASSESSMENT PROGRAM (NNAAP®)
RECIPROCITY APPLICATION
PLEASE PRINT LEGIBLY — USE INK ONLY
FOR
Pearson VUE
USE ONLY
PLEASE NOTE: This application will NOT be processed without verification of your paid employment as a nurse
aide within the previous 24 months (unless you were placed on the state registry within the previous 24 months).
Acceptable verification includes a copy of a W2 form or a pay stub from your employer. A nurse aide must
have completed, at a minimum, a 100-hour basic state-approved nurse aide course, including clinical
hours, in order to be placed on the South Carolina Nurse Aide Registry.
1. Social Security ■■■-■■-■■■■
Number:
Date of Birth:
■■/■■/■■■■
M M
D D
Y
Y
Y
Y
2. E-MAIL ADDRESS
3.PRINT FULL NAME
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■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■
LAST MIDDLE INITIAL
FIRST MAIDEN NAME (If Applicable)
3A. P
RINT FULL NAME AS IT APPEARS ON THE REGISTRY, IF DIFFERENT THAN ABOVE
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■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■
LAST MIDDLE INITIAL
FIRST MAIDEN NAME (If Applicable)
4.HOME MAILING ADDRESS
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STREET (number and name)
APARTMENT NUMBER
PO BOX
CITYSTATE
ZIP CODE
4. PHONE NUMBER
Daytime Phone Number:
■■■-■■■-■■■■
AREA CODE
5.
CERTIFICATION INFORMATION: YOUR APPLICATION WILL NOT BE PROCESSED WITHOUT THIS INFORMATION.
Provide the following information for the state in which you have been on a Nurse Aide Registry:
State of ■■
Certification Number*: ■■■■■■■■■■■■■■
Issue Date: ■■/■■/■■■■
Certification:
*Please provide a copy of your certificate, if you have one.
M M
D D
Y
Y
Y
Y
Application continues on following page
6. NURSE AIDE TRAINING PROGRAM INFORMATION
A nurse aide must have completed at a minimum, a 100-hour basic nurse aide course, which includes clinical hours.
I have attached a copy of:
■The certificate/diploma I received for completing the basic nurse aide course showing a minimum of 100 hours, or
■A transcript that verifies I completed a 100-hour state-approved basic nurse aide course, or
■ A notarized letter on school letterhead stating a 100-hour state-approved basic nurse aide course was completed.
7. Were you ever certified as a Nurse Aide on the South Carolina registry?
■ Yes
■ No
If you answered “Yes” to the above question, you must supply your South Carolina Nurse Aide Certificate Number.
South Carolina Nurse Aide Certificate Number:
■■■■■■
8. CRIMINAL CONVICTIONS If this section is not completed, your application will be returned.
Have you ever been convicted of or pled guilty to a felony? ■ Yes
State where you were convicted:
■■/■■/■■■■
■ No
Date(s) of conviction:
■■/■■/■■■■
M M
D D
Y
Y
Y
Y
9. S
UBSTANTIATED FINDING OF ABUSE Have you ever been listed on the South Carolina Abuse Registry
or any other state’s abuse registry?
■ No
■ Yes If “Yes”, name of state:
10. APPLICATION AFFIDAVIT
■■
(All candidates MUST sign.)
I understand that I am responsible for making sure that all of the information provided in this application is completely
true and correct. I understand that any information I give that is not true may jeopardize my certification status and
listing as a nurse aide, and may result in prosecution by the state of South Carolina.
SIGNATURE OF APPLICANT: ______________________________________________________________________________ DATE: _____________________________
MAILING INFORMATION
YOUR APPLICATION AND AND ALL REQUIRED DOCUMENTATION MUST BE MAILED TO:
Pearson VUE
South Carolina Nurse Aide Registry
PO Box 13785
Philadelphia, PA 19101-3785
Copyright © 2015 Pearson Education, Inc. or its affiliate(s). All Rights Reserved. [email protected]
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