Application

I certify by signature below that:

1. I have not been found guilty of abusing, neglecting or mistreating individuals by a court of law;

2. I am not the subject of a pending criminal charge of abusing, neglecting or mistreating individuals; or

3. I have no findings entered into the State Nurse Aide Registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property.

I understand that the above listed statements are not limited to the abuse, neglect or mistreatment of a resident or patient, but applies to any individual to whom I was in a responsible or care taker position. Furthermore, as terms of employment I understand that it is my obligation to inform the facility of any pending charges, pleas or convictions involving myself or any other employee of the facility.