Submit New Application

Non-Employer Renewal Application

Please read these directions completely before continuing to complete this form online. Your request for renewal cannot be processed if it is incomplete, illegible, or includes false statements.

Complete this form, upload the required documents, and pay the non-refundable verification and processing administrative assessment fee of $25 through the secure credit card processing portal.

Completing this form requires an uploaded image of either:
  • A paycheck stub or a W-2 showing proof of at least 8 hours working as a Nurse Aide in a  nursing home, hospital, or hospice within the previous 24 months.
You will be renewed on the Mississippi registry if you are qualified after the following is successfully completed:  
  • You have uploaded a paycheck stub or a W-2 from your out-of-state or closed-down employer.
  • The non-refundable verification and processing administrative assessment fee of $25 is included. 
Successful submission for Mississippi renewal can be verified by checking your status on the Mississippi NA Registry at https://ms.tmutest.com.

Your application is not complete until the required information is included, then select 'Send Application'.
Address
Recertification Information
Document Images
Affidavit
  • I have uploaded my paycheck stub or a W-2 from my out-of-state or closed-down employer. 
I agree that if all the requested documentation is not submitted with this application, and I do not reply to any of D&SDT-Headmaster's *emailed requests within one (1) month of submitting my application, my application will be denied, and I will need to resubmit a new application and repay the fee.

*NOTE: If you have an iCloud email, you may not receive our communications, and you may need to call to check your status.
By Submitting
I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.
Application Fee $25.00
Non-Refundable. All fees are non-refundable.
1.800.393.8664