Get Out-of-state Employment Verification Form - Ct.gov - Ct

This guide provides a comprehensive overview of the Out-of-State Employment Verification Form necessary for nurse aides who have worked outside of Connecticut. The instructions below will help users of all experience levels to accurately complete and submit the form.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the Out-of-State Employment Verification Form and open it in your preferred document editor.
2. In the section designated for the nurse aide, enter your full name, current address, and telephone number.
3. Provide your Connecticut Nurse Aide Registration Number along with your Social Security Number.
4. Answer the question regarding certification in other states. If you are certified in other states, please list those states clearly.
5. Next, move to the employer section. Fill in the facility or agency name where you were employed, and provide the address.
6. Indicate the date you were hired and the last reported date of employment. If you are currently employed, use today's date.
7. The form must be signed by the Director of Nursing or Administrator. They should also provide their telephone number and print their name beneath their signature.
8. Finally, review the entire form for accuracy. Once completed, save the changes, and be sure to download, print, or share the form as needed.

Complete your Out-of-State Employment Verification Form online today!