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Nurse Aide Signature I understand that by submitting this completed form for Verification of PA Residency to enroll in a nurse aide training program I am certifying that all of the information I have provided on this application is complete accurate true and correct. VERIFICATION OF PA RESIDENCY Please type or print legibly in ink. Date of Application Proposed Date of N*A. Class Enrollment I. Personal Information A Name B Current Address City State Zip Code C Months/Years at this Address D Telephone If you have resided at your current address for less than two years Previous Address If necessary attach a list of other places of residence to demonstrate that you have lived in Pennsylvania for the past two 2 years. II. Forms of Identification must be verified by program representative A Birth Date Month/Day/Year / / B Please provide two 2 additional forms of official signature-bearing identification one of which mustbe a current photo identification document. Examples of proper identification include Driver s License Passport Clinic card Credit card State-issued identification card Library card Alien registration card Other III. Education A Do you have a high school diploma or GED Yes No B Name of high school Address City State Dates Attended Date of Graduation C Did you attend an educational institution beyond high school Yes No If yes enter the name of the school s IV. I make this declaration subject to the penalties of 18 PA. C. S 4904 relating tounsworn falsification to authorities. VERIFICATION OF PA RESIDENCY Please type or print legibly in ink. Date of Application Proposed Date of N*A. Class Enrollment I. Personal Information A Name B Current Address City State Zip Code C Months/Years at this Address D Telephone If you have resided at your current address for less than two years Previous Address If necessary attach a list of other places of residence to demonstrate that you have lived in Pennsylvania for the past two 2 years. Class Enrollment I. Personal Information A Name B Current Address City State Zip Code C Months/Years at this Address D Telephone If you have resided at your current address for less than two years Previous Address If necessary attach a list of other places of residence to demonstrate that you have lived in Pennsylvania for the past two 2 years. II. Forms of Identification must be verified by program representative A Birth Date Month/Day/Year / / B Please provide two 2 additional forms of official signature-bearing identification one of which mustbe a current photo identification document. II. Forms of Identification must be verified by program representative A Birth Date Month/Day/Year / / B Please provide two 2 additional forms of official signature-bearing identification one of which mustbe a current photo identification document. Examples of proper identification include Driver s License Passport Clinic card Credit card State-issued identification card Library card Alien registration card Other III.

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