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Get TX DADS 5508-NAR 2007

Attach other documents as required below Mail all documentation to Texas Nurse Aide Registry P. O. Box 149030 MC E-414 Austin TX 78714-9030. You can download forms from our website http //www. dads. state. tx. us/providers/nf/credentialing/nar/forms. html Mail the completed form to the Texas Nurse Aide Registry address below. Mail Code E-414 P. O. Box 149030 Austin Texas 78714-9030 credential dads. Html Mail the completed form to the Texas Nurse Aide Registry address below. Mail Code E-414 P. O. Box 149030 Austin Texas 78714-9030 credential dads. state. tx. us With a few exceptions you have the right to request and be informed about the information that the Department of Aging and Disability Services DADS obtains about you. Texas Department of Aging and Disability Services Form 5508-NAR July 2014-E Texas Nurse Aide Registry Request for Reprint of Certificate and/or Correction to Nurse Aide Registry Data Please read all instructions before completing this form. Complete the following information. Attach a legible photocopy of a picture identification that shows your birth date and the correct spelling of your name. State. tx. us With a few exceptions you have the right to request and be informed about the information that the Department of Aging and Disability Services DADS obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS to correct information that is determined to be incorrect Government Code Sections 552. 021 552. 023 559. 004. To find out about your information and your right to request correction please contact the Nurse Aide Registry at 512-438-2050. I request the following check all that apply Correction to the Nurse Aide Registry database. The information provided below is correct. Reprint of certificate for the following reason Misprint on certificate received attach your certificate. Name Change Attach your certificate and a photocopy of your marriage license divorce decree or other court order indicating a name change. Original was lost stolen or destroyed* Other please specify Maiden Name if applicable Name of Applicant Last First Middle Social Security No* Sex Date of Birth mm/dd/yyyy Male Female Mailing Address Street or P. O. Box Rural Route Apartment Number etc* County City Area Code and Telephone No* State ZIP Code By my signature I certify that the information provided above is correct. Signature Nurse Aide Date Notes The Texas Nurse Aide Registry will return without action incomplete requests and requests without required documents. Tampering with or attempting to falsify a government record such as a nurses aide certificate is a third-degree felony punishable by up to 10 years in prison and a 10 000 fine. Page 2 / 07-2014-E Address Applicant did you sign the form specify why you are requesting reprint of certificate include a legible photocopy of your picture identification showing your birth date and the correct spelling of your name attach a photocopy of your marriage license divorce decree or other court order for name change attach your certificate if request is for reprint Did you know You can verify certificate status by calling 1-800-452-3934. .

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