Renewal Application Medication Aide Program

Medication Aide Program Renewal Application
APPLICATION INSTRUCTIONS:
1. Submit this online renewal application.
2. Submit the payment form according to instructions.
Date of application*

MonthDayYear
Date
Type of program*
Type of training program*
Agency Information
Legal name of agency*
Alternate name
Agency address*

Address

Address Line 2

CityState

Zip Code
Agency telephone number*
Please enter a valid phone number.
Type of agency*

Long term careSkilled nursingAssisted LivingICF/IDDDD WaiverEducation only
Owner name*

First NameLast Name
Owner mailing address*

Address Line 1

Address Line 2

CityState

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 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

Medication Aide Program Renewal Application