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.
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.
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.
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?*

YesNo
Are there sufficient resources available to meet the needs and purpose of the program?*

YesNo
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).*

YesNo
Submitted by: Name*

First NameLast Name
Position/Title*
Telephone number*
Please enter a valid phone number.
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.
Signature*

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Hemodialysis Technician Program Renewal Application

Agency & Program Information