NOTE:
You must attach a separate sheet of paper if you had more than two employers where you performed nursing or nursing-
related tasks delegated and supervised by a Registered Nurse in the past 2 years only (previous 24 consecutive months).
Do not include private duty nurse aide employment.
PART 7: IDENTIFICATION
▪ Include a copy of your social security card with the submission of your application.
▪ Include a copy of an unexpired government-issued identification containing a photograph and signature with
the submission of your application.
▪ The name listed on your social security card and unexpired government-issued identification containing a
photograph and signature must match.
▪ The name listed on both identifications must match the name listed on the nurse aide registry in the State(s)
of reciprocity.
▪ If the names do not match, then you must submit documentation verifying any name changes (e.g., birth
certificate, marriage license, divorce decree, notice of resumption of former name, etc.).
▪ Copies of identifications received by fax may not be readable. Please ensure copies of your identifications
are readable before submitting your application. If your identifications are not readable, then you will be
asked to re-submit the application and your identifications again.
The Following are Acceptable Government-Issued Identifications Containing a Photograph and Signature:
• Current, non-expired driver’s license (or expired driver’s license and temporary permit)
• U.S. government-issued Military I.D.
• State-issued identification card
• Passport (US or foreign, current, non-expired)
• Current, non-expired federal-issued employment authorization document (EAD) photo identification card
• Alien registration card
PART 8: APPLICANT SIGNATURE
I certify that all the information provided in this application is true and complete. I understand that if the
information I have provided in this application is found to be fraudulent, then my listing will be removed from the
North Carolina Nurse Aide I Registry and I will be required to pass a North Carolina state-approved nurse aide I
training program and the North Carolina state-approved nurse aide I competency examination. I give my
permission to any state registry to disclose all information requested in this application to the North Carolina
Division of Health Service Regulation, Health Care Personnel Education and Credentialing Section.
First Name (print): _________________________________________________________________________________
Middle Name (print): _______________________________________________________________________________
Last Name (print): _________________________________________________________________________________
Signature: _________________________________________________ Date: ________________________________
REMINDER:
You Must Submit All Pages of the Application (Pages 1 through 6), Your Social Security Card, and a
Current Government-Issued Identification with Photograph and Signature for Review and Approval.