Registration for Private Duty
Maryland Application

Date:

Name:

Email Address:

Home Phone:

Other Phone :

Street:

State:

City:

Zip Code :

Position (choose one):
RN LPN GNA CNA CMA NA

License or Certification No. Expiration Date:

Have you ever worked under another name?
Yes   No

If yes, what other names or names?

Are you a U.S. Citizen?
Yes   No

If No, do you have a Resident Alien Card? Yes   No

Card # Expiration Date:
(Verification will be required upon hire)

Have you ever been convicted of a felony or misdemeanor including abuse or neglect of a resident or resident’s property (do not include minor traffic violations).
Yes No

If yes give details.

Do you have current CPR?
Yes No
Expiration Date:

Date of last physical (month & year).

Date of last TB test. neg. pos.

How much experience do you have in patient care?

Do you have malpractice insurance?
Yes No Expiration Date:

A brief description of the care you may have to provide may include, but not limited to: bathing, dressing, feeding, transferring or lifting patients.
Are you able to perform these functions? Yes No

If no give explanation.

Do you have your own car? Yes No

Are you presently working? Click Here... yes no full-time part-time

Which days you are able to work:
SUN: MON: TUES: WED: THURS: FRI: SAT:

STATEMENT OF CERTIFICATION
I understand that inquires may be made to the references listed above or their agents, and to others with whom I have been acquainted; and that those inquires may include information regarding my character, my general reputation, my personal characteristics, and my overall working attitude. My permission is hereby granted to make such inquires.

I understand that I am registered on a temporary basis with no guarantee of any minimum hours of work and no guaranteee that work will be available at all.

I understand that the following circumstances are causes for IMMEDIATE REMOVAL from the registry:

1. Verbal or physical abuse of a patient, patient’s property, patient’s family, or office personnel. This includes neglect.
2. Numerous complaints regarding work performance or attitude.
3. Theft or borrowing of money or possessions.
4. Falsification of a time slip.
5. Absence without notifying the office or answering service.
6. Continual lateness and/or frequent cancellations.
7. Performance or unauthorized medical procedures.
8. Failure to perform prescribed duties.
9. Use of or be under the influence of drugs or alcohol.
10. Any misrepresentation or lies on the registration form.

I understand the above Statement of Certification and the causes for immediate removal from the registry. I hereby certify that the answers given by me to all questions contained on this form are true and correct. Yes No

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