Get Ca 55a-12 2018-2025

This guide provides clear instructions on how to complete the CA 55A-12 Employment Verification Form for Nursing Experience online. Follow the steps carefully to ensure that your form is filled out accurately and submitted correctly.

Follow the steps to complete the CA 55A-12 Employment Verification Form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill out Part I of the form, including your name, address, and contact information. Make sure to provide your name while employed and your social security number.
3. Print copies of Parts II through IV to provide to each employer you have worked for in the last ten years. Ensure that these pages are submitted to the RN Director or RN/LVN Supervisor for completion.
4. Ask your supervisor to complete Parts II through V. Part II requires the facility name and type where you gained experience. Ensure this information is accurately filled out.
5. Instruct your employer to provide the specific employment dates and work hours in each relevant nursing area in Part III. A detailed breakdown of hours worked in each area is necessary.
6. Have your employer check whether you have satisfactorily demonstrated the required skills in Part IV. They should indicate 'Yes' or 'No' for each skill listed.
7. Finally, ensure that the RN Director or RN/LVN Supervisor signs Part V, including their nursing license number and contact information. Collect the form in a sealed business envelope.
8. Submit the unopened sealed envelopes containing the Employment Verification Forms along with your application for licensure to the Board.
9. Keep copies of all forms for your records. Once submitted, ensure to monitor the application process for any updates.

Start completing your CA 55A-12 Employment Verification Form online today to ensure your licensure application proceeds smoothly.