Texas Department of Aging |
Form 5508-NAR |
and Disability Services |
July 2014-E |
Texas Nurse Aide Registry
Request for Reprint of Certificate and/or
Correction to Nurse Aide Registry Data
Please read all instructions before completing this form. Complete the following information.
●Attach a legible photocopy of a picture identification that shows your birth date and the correct spelling of your name.
●Attach other documents as required below
Mail all documentation to Texas Nurse Aide Registry, P.O. Box 149030, MC E-414, Austin, TX 78714-9030. I request the following (check all that apply):
Correction to the Nurse Aide Registry database. The information provided below is correct.
Reprint of certificate for the following reason:
Misprint on certificate received (attach your certificate).
Name Change (Attach your certificate and a photocopy of your marriage license, divorce decree or other court order indicating a name change).
Original was lost, stolen or destroyed.
Other
(please specify)
Name of Applicant (Last, First, Middle) |
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Maiden Name (if applicable) |
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Social Security No. |
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Sex |
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Date of Birth (mm/dd/yyyy) |
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Male |
Female |
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Mailing Address (Street or P.O. Box, Rural Route, Apartment Number, etc.) |
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County |
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City |
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State |
ZIP Code |
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Area Code and Telephone No. |
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By my signature, I certify that the information provided above is correct.
Signature – Nurse Aide |
Date |
Notes:
●The Texas Nurse Aide Registry will return (without action) incomplete requests and requests without required documents.
●Tampering with or attempting to falsify a government record such as a nurses aide certificate is a third-degree felony punishable by up to 10 years in prison and a $10,000 fine.
Form 5508-NAR
Page 2 / 07-2014-E
Address:
Applicant, did you:
●sign the form?
●specify why you are requesting reprint of certificate?
●include a legible photocopy of your picture identification showing your birth date and the correct spelling of your name?
●attach a photocopy of your marriage license, divorce decree or other court order for name change?
●attach your certificate if request is for reprint?
Did you know?
●You can verify certificate status by calling 1-800-452-3934.
●You can download forms from our website: ht t p:/ / w w w .dads.st at e.t x.us/ pr ovider s/ nf / cr edent ialing/ nar / f or m s.ht m l
Mail the completed form to the Texas Nurse Aide Registry address below.
Texas Nurse Aide Registry
Mail Code E-414
P.O. Box 149030
Austin, Texas 78714-9030
credential@dads.state.tx.us
With a few exceptions, you have the right to request and be informed about the information that the Department of Aging and Disability Services (DADS) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact the Nurse Aide Registry at 512-438-2050.
