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Get Nebraska Nurse Aide Registry Forms

-12 NURSE AIDE TERMINATION FORM FACILITY CITY STATE ZIP SOCIAL SECURITY NUMBER OR REGISTRY NUMBER INDIVIDUAL'S NAME (Last) (First) (Middle) DATE TERMINATED Please return this form to: Nebraska Nurse Aide Registry PO Box 94986 Lincoln, NE 68509-4986 Fax: 402-471-1066 Rev 02-12 http://dhhs.ne.gov/publichealth/Documents/term.pdf.

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