Get Nc Dhhs Dhsr/hcpec 4502 2015

The NC DHHS DHSR/HCPEC 4502 form is an essential document for individuals seeking to be listed on the North Carolina Nurse Aide I Registry. This guide will walk you through the process of completing this form online, ensuring that you understand each section and field to facilitate a smooth submission.

Follow the steps to complete the NC DHHS DHSR/HCPEC 4502 online

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editing tool.
2. Begin by filling out the RN or LPN information section. Ensure your name is entered exactly as it appears on your nursing license. If applicable, include your maiden name.
3. Enter your full social security number voluntarily in the designated field. This number will be used strictly for record-keeping purposes.
4. Provide your RN or LPN license number as required for your registration.
5. Next, fill out personal information including your mother’s maiden name, date of birth in the format of Month/Day/Year, and the state where your license was issued.
6. Indicate your license type by checking either 'RN' or 'LPN', and if you are a new graduate, include your date of graduation.
7. Complete the mailing address section with your street address or P.O. Box, along with your city, state, and zip code.
8. Input your home and work telephone numbers, and include your email address for any correspondence.
9. Answer the question regarding whether you have previously been listed on the NC Nurse Aide I Registry, marking 'YES' or 'NO', and include your NC Listing number if applicable.
10. Provide your signature in the designated area, acknowledging the disclosure and authorizing the verification of your request to be listed.
11. Lastly, complete the additional survey questions if you wish. Though not required, these responses can be valuable for the review process.
12. Once all fields are thoroughly completed, save your changes, and prepare to download, print, or share the completed form as needed.

Complete your NC DHHS DHSR/HCPEC 4502 form online today and ensure your application is processed efficiently.