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Healthcare Workers Bridge

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Date / Time

Date

Time

Name

First

Last

Certification provided your

Phone

What Certification Bridge Program you are applying for

Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended, etc.) against you?

List current or most recent facility, agency, or organization you are or were employed with. Current Employer

If yes, indicate the type and number of license/certificate:

What Certifications do you currently Hold

I have provided my skills or allied health-related services in a facility to residents for compensation (under the supervision of a licensed health professional) within the scope of practice of the certification I am applying for within the past 2 years

Employers Address

Address Line 1

Address Line 2

City

State

Zip Code

Employers Email

Employers Phone Number

Direct Supervisors Name

I certify, under penalty of perjury under the laws of the State, that the foregoing is true and correct

Share any additional information you feel may be helpful

Confirmation

I acknowledge that my renewal is final and that I cannot cancel my membership until it expires.

Confirmation * • I acknowledge that my application can not be canceled. Select the certification you wish to renew. Please take note if there is a credit card chargeback related to this transaction, certification will be revoked immediately and your employer will be notified of your certification status. * You will also be listed on the national chargeback system *

Valid Photo ID is required Please Upload Here

Click or drag files to this area to upload. You can upload up to 100 files.

Signature

Clear Signature

Certification Bridge Application Fee

Healthcare Workers Certification Bridge Form – $698.00

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