Nurse AIDE Training Program Application for Enrollment Question Title * 1. Last 4 digits of SS# Question Title * 2. Last Name Question Title * 3. First Name Question Title * 4. Middle Initial Question Title * 5. Address Question Title * 6. Apt# Question Title * 7. City Question Title * 8. State Question Title * 9. Zip Code Question Title * 10. Telephone # Question Title * 11. Email Address Question Title * 12. Are you at least 18 years old Yes No Question Title * 13. Can you show proof of legal authorization to work in the U.S. Yes No Question Title * 14. Are you now or have you ever been sanctioned, excluded, debarred, or suspended by the OIG (Office of Inspector General) or any state or federal healthcare program? Yes No Question Title * 15. Has there ever been a finding of patient or resident abuse against you? Yes No Question Title * 16. If yes, describe and state the nature of the finding(s) and where the finding(s) occurred and the date of the finding(s) Question Title * 17. Have you ever been issued a Healthcare license/registration/certification by any local, State, or Federal Agency? Yes No Question Title * 18. If yes, list the specific Healthcare license/registration/certification issued to you and include the name of the license/registration/certification, the issuing authority, date the license was issued and its expiration date. Question Title * 19. Do you have a High School Diploma or GED? Yes No Question Title * 20. If yes, please enter the name of the High School or GED program you received your diploma from: Question Title * 21. If Yes,enter the address of the High School or GED program. Question Title * 22. Please read carefully and sign : I certify that this application was completed by me and the entries contained are true and complete. I understand any false statements made on this application or misrepresentation or omission of facts requested on this application are grounds for rejection of this application or dismissal from the Hebrew Home at Riverdale Training Program.Enter Full Name Question Title * 23. Enter completion Date Date / Time Date Question Title * 24. Upload your High School Diploma or GED PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Upload your High School Diploma or GED Question Title * 25. Upload your Driver's license or Non-Driver ID Card PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Upload your Driver's license or Non-Driver ID Card Question Title * 26. Upload your Authorization to Work in US if Non- Citizen PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Upload your Authorization to Work in US if Non- Citizen Done
