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CNA RECIPROCITY FORM Application

Please read these directions before you complete and submit this form. Your request for reciprocity cannot be processed if it is incomplete, illegible, or includes false statements.

You are eligible for Reciprocity into Mississippi if you meet the following qualifications:

You have an active certification in good standing in another state
You have worked 8 hours in a nursing home, hospital, or hospice
- You must upload a paycheck stub or W2 showing work within the past 24 months

**NOTE: If you have been a CNA for six months or less and have not worked as a CNA, you will have to provide a copy of your certificate of completion from your training program showing the completion date in lieu of a paycheck stub or W2 (in the Proof of Work section).

Acceptable proof of training includes:

A copy of your certificate of completion, diploma, or transcripts from your training program (with date of completion),
Or a letter from your training program stating where and when you completed the training

Complete this form. Attach the required training and identification documents. Pay the non-refundable reciprocity verification and processing administrative assessment fee of $25 through the secure credit card processing portal. Please note: Completing this form requires the following attachments:

Proof of Work and/or Training Certificate
Image of your social security card
Image of your valid US government-issued photo identification (state driver’s license, passport, or other signed current photo identification).

Your application is not complete until the required information is included, then select 'Send Application'.

Legal First Name

Middle

Legal Last Name

Suffix

Birthdate

Phone

SSN

Address

City

State

Zipcode

Reciprocity Information

Reciprocity License Number If you have a license in another state, please provide your license number.

Reciprocity License State

Certification Select the certification type you are applying for.

Current State where you are listed on the Nurse Aide Registry. Please select the state you are currently listed on the Nurse Aide Registry.

List other states where you have been listed on the Nurse Aide Registry:

REQUIRED QUESTION

Do you have substantiated finding of abuse, neglect or misappropriation of a client's property on another Registry?

If you answered YES, please explain: If you answered YES, please explain.

IDENTIFICATION DOCUMENTS

Image of your valid US government-issued, signed photo identification, such as: → state driver’s license, → passport, → or other signed, current, photo identification Image of your valid US government-issued, signed photo identification.

Image of your Social Security Card Image of Social Security Card.

PROOF OF WORK

Image of your paycheck stub or W2 from an acceptable health care facility: You must have worked 8 hours in a nursing home, hospital, or hospice, and you have to upload a paycheck stub or W2 showing work within the past 24 months. **If you have been a CNA for six months or less and have not worked as a CNA, you can provide a copy of your certificate of completion from your training program showing the completion date in lieu of a paycheck stub or W2 here.**

Affidavit

I have uploaded my current US government-issued, signed photo ID.
I have uploaded my social security card.
I have uploaded either proof of work or proof of training

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.

I understand that my application will be denied if D&SDT-Headmaster:

Is unable to verify my registry status on another state's nurse aide registry.
If I have listed an offense on my application.

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.

Cardholder Name

Card Number

Exp Month

Exp Year

Security Code

Cardholder Address

City

State

Zip Code