When completing the application, you are required to submit your social security number in accordance with West Virginia Code § 48-18-133 and 42 U.S. Code § 666. If you fail to do so, the processing of your application will be suspended. Your social security number will be used by the Office of Health Facility Licensure and Certification for identification purposes only and will not be disclosed for other purposes except as provided for by law. Federal and state law requires that this number be shared with other agencies for child support enforcement activities.
By signing this application, I verify that I have submitted true and accurate information. I also understand that if I have submitted any false information on this application registration will be denied and my name will not be added to the West Virginia Nurse Aide Registry. In addition, I hereby give my permission for the state nurse aide registries listed on this application to release information to the state of West Virginia for certification verification.