Form 1402 Ok – Fill Out and Use This PDF

D&S DIVERSIFIED TECHNOLOGIES LLP dba HEADMASTER LLP

PO BOX 6609 HELENA MT 59604

TELEPHONE: 800-393-8664 FAX: 406-442-3357

EMAIL: hdmaster@hdmaster.com

WEB SITE: www.hdmaster.com

TESTING AND REGISTRY APPLICATION RATE STRUCTURE

DIRECTIONS

1.Do not need to fill out this form if you are using Webetest (On-Line testing)

2.Mail completed forms at least 10 working days prior to requested test date

3.Complete one Form 1402OK (this form) for each group of Candidates

4.For initial applications include one Form 1101OK (CNA application) for each candidate

5.For retest applications include Form 1301OK (test results) for each candidate

OPTION 1 FIXED Test Dates - Candidates that must use Fixed (Regional) Test sites

1st Choice	Test Site Name____________________________ 4 Digit Test Site # ______________Test Date________________
2nd Choice	Test Site Name____________________________ 4 Digit Test Site # ______________Test Date________________

OPTION 2 Approved Flexible Test Sites – Only In-Facility Training & Educational Programs testing in their own facilities

Name of Test Site ________________________________________________ Date test will be given _______/________/_______

Email ________________________________________ Phone (______) ________-_________ Digit Test Site ID # _______________

Address __________________________________________________ City __________________ State __________ ZIP ___________

Name Test Observer ________________________________________ Contact Person’s Name ______________________________

For ADA Accommodations attach authorization from OSDH.			Tests / Service	# Requested	Per	Total
					Candidate	Cost
PRIORITY FAX SERVICE (Optional) Fax 406-442-3357 available
			Written Test		$20.00ea
Monday-Friday 8:00am-3:00pm EST – Holidays Excluded.
Applications will be processed and test confirmation letters mailed			Oral Test		$35.00ea
on the day the applications are received by fax OPTIONAL
			Skill Test		$75.00ea
EXPRESS Overnight SERVICE: Application(s) must be received
five workdays prior to 1st requested test date. An additional $15
			Priority Fax Service		$5.00ea
per candidate plus express overnight shipping charge of $19.50
			Overnight Shipping		$19.50
apply. (No additional Fax charges apply) If you fax in your
			Express Service Fee		$15.00ea
application please do not mail the original. WEBETEST© High
Volume users Internet electronic application submission.			No Show		No
Call 1-800-393-8664 for more information. NO PERSONAL					Refund
			Reschedule		$35.00
CHECKS. Candidates may ONLY send cashiers check, money
order, or use Visa/MC. Mail to PO Box 6609 Helena, MT 59604.			Cancellation		$25.00
				Grand Total Enclosed $_________

If Facility paid then Facility name and address_____________________________________________________________________

Credit Card # (Visa, MC)___________________________________________________Expiration Date ___________/___________

Name as it appears on credit card ________________________________ Authorized Signature __________________________

Candidates CURRENTLY EMPLOYED, AS NURSE AIDES IN SKILLED MEDICARE/MEDICAID FACILITIES THAT ARE PARTIALLY REIMBURSED BY OKDH DO NOT INCLUDE FULL PAYMENT. Please call OKDH for questions about reimbursement status. Must list the Name and Location of the reimbursed Facility

Facility name and address_____________________________________________________________________________________________________

Phone (______) ________-_________ Contact Person’s Name ______________________________________________________________________

The submission of this application certifies that Testing Services are requested for the candidates included. D&SDT is hereby authorized to proceed with testing and the applicant(s) understand(s) and agree(s) to abide by D&SDT testing, retesting, scheduling, rescheduling, cancellation, and No show policies.

Authorization Signature________________________________ Print Name_________________________________Phone (_____) ______-______

FORM 1402 OK

Updated: 11/16/2005