NATIONAL HEALTHCARE WORKERS ASSOCIATION (NWCWA) RENEWAL APPLICATION Certification Renewal Fee $105

Directions: This form must be completely filled out, and faxed to 877-560-9486, or mailed to NHCWA 378 Boston Post Road suite 1000 Orange CT 06477. *The applicant and their supervisor must sign the renewal application, or the applicant must provide (CEU) verification. Certification renewal qualifications stated on Page 3 in section C. must be satisfied for renewal of NHCWA certification. *Please include the $105 renewal fee for each certification you are applying to renew *this application will not be processed without the full $105 renewal fee. Renewal fee can be mailed to NHCWA or paid online, by following the instructions on the certification renewal page located under the about tab on our website.

APPLICANT INFORMATION:

Name: Phone:( )

Address:

City: State: Zip _________ E-Mail Address:

List current or most recent facility, agency, or organization you are or were employed with.

Current Employer: Work Title:

Employer Address: ______________________________________ Work Phone: ( ) ___________

Job Duties: _________________________________________________

Supervisors Name: ___________________________ Title:

Date: Supervisor’s Phone: ( ) ___________

I certify that the information above is correct: yes or no ** Supervisors Signature: ___________________________ Title:

TYPE OF REQUEST (Check all that apply. See additional information on page 3 of this form.)

1. NHCWA Renewal

Certification type & name:

Certification number: ______Date issued: ______________

Certification Organization:

2. Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended, etc.) against you? - If yes, indicate the type and number of license/certificate: Yes No

3. I have successfully completed eight-hour (8) hours of in-service/continuing education (CE) hours during my most recent certification period (eight (8) hours per every 2 years). Yes No

4. I have provided my skills or allied health-related services in a facility to residents for compensation (under the supervision of a licensed health professional) within my most recent certification period (eight (8) hours per every 2 years). Yes No

REACTIVATION:

5. NHCWA APPLICANTS ONLY:

I have not completed both renewal requirements listed above (Questions 3 or 4); therefore, I wish to reactivate my NHCWA certification by passing the competency evaluation (Testing). (Please review Section C on this application. Testing information will be sent to you.

I certify, under penalty of perjury under the laws of the State, that the foregoing is true and correct. Yes No

Signature of applicant: ___________________________ Date:

C.

NHCWA RENEWAL You may submit a renewal application any time within two (2) years of the expiration date of your certification, if by the time your certificate expires you will have completed the following:

•You have previously maintained have provided your skills or allied health-related services in a facility to residents for compensation (under the supervision of a licensed health professional) within your most recent certification period.

•You provided patient care or patient care-related services to residents in a facility for compensation (under the supervision of a licensed health professional) within your most recent certification period.

•You have successfully completed eight (8) hours of in-service/CE hours. (At least four (4) of the eight (8) hours of in-service/CE hours shall be completed each year.)

NHCWA REACTIVATION

If you are unable to meet the renewal requirements and your certification has not expired over two (2) years, you may submit this completed application for REACTIVATION without re-training. If you are qualified, NHCWA will approve your application for the competency evaluation and will send you information about taking the competency evaluation (Testing). You will not receive certification until the NHCWA approved testing vendor notifies us that you have successfully passed the competency evaluation.

*NAME AND ADDRESS CHANGES*

The Certification Holder is responsible for notifying NHCWA, within sixty (60) days, whenever changes of their name, address, or telephone number occur. If they have had a name change, they must submit legal verification of the change. Indicate the certificate number for identification purposes. Failure to do so could result in the delay or loss of the certification.