SECOND DEGRE (Partie 2)
Une vérification à l'aide de la calculatrice n'est jamais inutile ! On peut lire une valeur approchée des racines sur l'axe des abscisses. Un logiciel de calcul
STATE OF CONNECTICTUT DEPARTMENT OF PUBLIC HEALTH
Connecticut Nurse Aide Employment Verification Form. This form is to be used for verifying nurse aide or nursing-related employment for the purpose of
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09-Jul-2005 L'ENSEIGNEMENT SECONDAIRE DES MATHEMATIQUES EN FRANCE ET EN ALLE- ... isocèle pourra être effectuée par vérification à l'aide du compas et ...
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STATE OF CONNECTICTUT
DEPARTMENT OF PUBLIC HEALTH
8/2016
Connecticut Nurse Aide Employment Verification FormThis form is to be used for verifying nurse aide or nursing-related employment for the purpose of maintaining current status on the Connecticut
Nurse Aide Registry. Should you have any questions with the completion of this form, please call the Nurse Aide Registry staff at (860) 509-
7603 * Press option #1. (To verify a nurse aide certificate expiration date please visit: https://registry.prometric.com/publicCT )
To Be Completed By Nurse Aide
Name: __________________________________________________________________________ Current Address: __________________________________________________________________________ _________ Telephone Number: _______________________ E-mail: _______________________________________Connecticut Nurse Aide
Registration Number: __________________________________________ ________ Social Security Number: ________________________________DOB: __________________________
Are you certified in any other states as a nurse aide? ____________________If you answered "Yes", please
identify the other states in which you are certified:_______________________________________________To Be Completed by Employer:
Please Check Appropriate Box: Facility/Agency: Private Duty: Out of State:
The person identified above is/has been employed as a certified nurse aide or in a position where they perform/ed
nurse aide duties by the following (please print): Facility/Agency/Employer Name: __________________________________________________________Address:
Employer Code (if applicable): ____________________ Date of Hire: ____________________ Last Reported Date of Employment: _______________ (If currently employed use today's date.)If you work for a physician's office or as a private duty nurse aide, please provide a description of the specific
n u rs i n g o r n u rs i n g rel a t ed a ct i v i t i es p erf o r m e d (you can attach an additional sheet if necessary):I certify that all of the information contained herein is true and accurate to the best of my knowledge and belief:
___________________________________________ _____________________________Employer Representative
(Please Print) Telephone Number __ _____________________________ Signature of Employer Representative DatePlease note: this form must be completed in its entirety and mailed or faxed directly from the employer to:
CT Nurse Aide R
egistry ProgramDepartment of Public Health
410 Capitol Avenue, MS#12MQA
P.O. Box 340308
Hartford, CT 06134-308
Facsimile: (860) 707-1983
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