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To apply, complete this application and send it to Allison Ortner at?ortnera@brcc.edu?and Carol Anderson at?andersonc@brcc.edu?along with:a copy of the current Virginia Nurse Aide certification;proof of being a certified nurse aid for at least three years, such as a letter from your employer or a screen shot or copy of your certification from the Virginia Department of Health Professions?License Lookup; anda recommendation for advanced certification from a licensed nurse who has supervised the applicant in providing direct patient care for at least six months within the past year.NAME:___________________________________________SOCIAL SECURITY # (last four digits):___________________DATE OF BIRTH: ____________________Gender:_________ADDRESS:_______________________________________CITY:__________________STATE:_____ZIP:__________EMAIL ADDRESS:___________________________________EMPLOYER:______________________________________WORK PHONE:___________________________________The information collected on this form is very important as we receive partial funding based on documenting participation. As a result, we are able to keep our costs as low as possible. We will also create a non-credit transcript for each person who fully completes the form. Transcripts will be available by request indefinitely. ................
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