Hemodialysis Technician Program Renewal Application

Hemodialysis Technician Program Renewal Application
APPLICATION INSTRUCTIONS: The application is not complete until the application has been submitted and the application fee has been paid.
1. Complete and submit this online renewal application.
2. Complete the payment form and submit following instructions on the form.
Date of application

MonthDayYear
Date
Agency & Program Information
Legal name of agency including program name
Alternate name
Agency address

Address Line 1

Address Line 2

CityState

Zip Code
Agency telephone number
Please enter a valid phone number.Format: (000) 000-0000.
Owner name
Owner mailing address

Address Line 1

Address Line 2

CityState / Province

Postal / Zip Code
Administrator name

First NameLast Name
Administrator telephone number
Please enter a valid phone number.Format: (000) 000-0000.
Administrator email address
example@example.com
Name of nurse educator

First NameLast Name
Nurse educator license number
Telephone number of nurse educator
Please enter a valid phone number.Format: (000) 000-0000.
Email address of nurse educator
example@example.com
Name of nursing director

First NameLast Name
Name of medical director

First NameLast Name
New Mexico Department of Health license number
Expiration date of current Department of Health license

MonthDayYear
Date
Date of last Board of Nursing program review

MonthDayYear
Date
Does the program utilize clinical preceptors?
Are there sufficient resources available to meet the needs and purpose of the program?
I understand that hemodialysis technician rules require that certain program changes must be reported to the Board of Nursing for approval (16.12.4.13 NMAC).
Submitted by: Name

First NameLast Name
Position/Title
Telephone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
By digitally signing below, I attest that all the information provided in this webform is true, accurate, and complete to the best of my knowledge. I understand that any false or misleading information may result in consequences as determined by applicable laws and regulations. I acknowledge that the digital signature is my legally binding electronic signature for this document.
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Hemodialysis Technician Program Renewal Application

Agency & Program Information