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Renewal Form Gally Michel
Renewal Form Gally Michel
Certification#: NA8245911 Issue Date: Jun 23, 2004 Expiration Date: Aug 9, 2021
Certificate Holder Address: Please check here if your address has changed and enter the changes in Section 6 below.
GALLY MICHEL
24 Raven Ave
PISCATAWAY, NJ 08854
PLEASE NOTE THAT THIS RECERTIFICATION FORM MUST BE SUBMITTED IN ACCORDANCE WITH THE PROCEDURE SET FORTH IN
SECTION 4 OF THIS FORM PRIOR TO THE EXPIRATION DATE SHOWN IN SECTION 1 . FAILURE TO RENEW YOUR CERTIFICATION BEFORE
THE EXPIRATION DATE WILL RESULT IN THE IMMEDIATE EXPIRATION OF YOUR CERTIFICATION, AND YOU CANNOT WORK AS A NURSE
AIDE IF YOUR CERTIFICATION HAS EXPIRED.
IF YOU DO NOT SUBMIT THIS RECERTIFICATION FORM PRIOR TO THE EXPIRATION DATE, YOU CANNOT RENEW YOUR CERTIFICATION.
YOU WILL THEN HAVE TWO OPTIONS:
1. IF YOUR INITIAL CERTIFICATION WAS ISSUED WITHIN THE LAST FIVE YEARS, YOU CAN REQUEST A WAIVER; OR
2. IF YOUR INITIAL CERTIFICATION WAS ISSUED MORE THAN FIVE YEARS AGO, YOU MUST RE-TRAIN AND SIT FOR THE EXAMS.
QUESTIONS ABOUT THESE OPTIONS SHOULD BE REFERRED TO THE CERTIFICATION PROGRAM AT (609) 292-5441.
Section 2 – Declaration and Signature of Administrator/Designee
(This section must be completed by a LICENSED HEALTH CARE FACILITY EMPLOYER)
Facility Name: Facility Address:
The above-named has been employed either directly in or under supervision by (name of health care facility)
providing nursing or nursing related services for pay for at least 7 hours within the last 24 months prior to the expiration
date on the certification. I certify that the information put forth on the recertification form is true and correct to the best of my knowledge.
I agree that the NJDOH may investigate the accuracy of the information contained on this form. I hereby given permission for NJDOH to obtain and/or
update criminal history information from the New Jersey State Police and the Federal Bureau of Investigation. I have been employed a licensed health
care facility or under the supervision of a licensed health care facility providing nursing or nursing-related services for at least 7 hours for pay within the
24 months prior to the expiration date on my certificate. I understand that if I have given false information on this document, I may lose my certification.
I have read and understand the information and authorize the placement of my name on the Nurse Aide Registry.
Voucher Code:
Address1:
Address2:
City: State: Zip Code:
Section 7 – PSI Services Assessment Center Locations and Recertification Times
NOTE: Person(s) accompanying a recertification candidate may not wait in the test center, inside the building, or on building property. This applies to
guests of any nature, including drivers, children, friends, family or colleagues.
North Brunswick, NJ 08902 Monday From I-95 South/New Jersey Turnpike South:
10:00am-4:00pm Take Exit 9 toward US-1/New BrunswicK/Princeton/
Trenton/Tower Center Blvd.Stay straight to go onto NJ-18N.
Merge onto US-1 S towards Trenton.
The Shoppes at North Brunswick Take the right-171 N ramp towards New Brunswick.
980 Shoppes Blvd, 2nd floor Turn left onto US-130/St. Georges Road.
Turn right onto Shoppes Blvd. 980 is on the right.