Submit New Application

AR CNA Reciprocity 9110AR Application

DO NOT COMPLETE THIS FORM if you have ever previously been listed on the Arkansas Nurse Aide Registry. You can check for the status of your AR listing on the Arkansas NA Registry at: https://ar.tmutest.com

Please read these directions completely prior to continuing and submitting this form. Your request for reciprocity cannot be processed if it is incomplete, illegible, or includes false statements.

Complete this form 9110AR, upload the required identification documents, and pay the non-refundable processing fee of $25 through the secure credit card processing portal. Completing this form requires an uploaded image of your:

Social security card and;
An image of your valid US government-issued photo identification (state driver’s license, passport, or other signed, current, photo identification)

Your application is not complete until the required information is included, then select “Send Application.”

Legal First Name

Middle

Legal Last Name

Birthdate

Phone

SSN

Gender

Male Female Other

Address

City

State

Zipcode

Reciprocity Information

Reciprocity License Number If you have a license in another state, please provide your license number.

Reciprocity License State Please select your reciprocity license state.

Certification Select the certification type you are applying for.

List all the states where you are listed on a Nurse Aide Registry:

Military Member Status

Are you a veteran, active duty or spouse of a veteran? If you checked YES, please fill out and submit the 'AR Military Expedited Licensure Form' available on the Arkansas NA webpage at www.hdmaster.com.

Select which one applies:

Required Questions

HAVE YOU EVER BEEN CONVICTED OF ABUSE OR NEGLECT OF A PERSON IN YOUR CARE, THEFT FROM A PERSON IN YOUR CARE, OR CHILD ABUSE?

If you answered YES, please explain. If you answered YES, please explain.

ARE YOU CURRENTLY UNDER INVESTIGATION FOR ABUSE OR NEGLECT OF A PERSON, THEFT FROM A PERSON, OR CHILD ABUSE?

If you answered YES, please explain. If you answered YES, please explain.

Images of the following documents must be included.

Image valid US government-issued photo identification, such as: → state driver’s license, → passport, → or other signed, current, photo identification Image of your valid US government-issued photo identification.

Image of your Social Security Card Image of Social Security Card.

Affidavit

I have uploaded my current US government-issued, signed photo ID.
I have uploaded my social security card.
- *NOTE: If you have an iCloud email, you may not receive our communications and you may need to call to check your status.

I agree that if all the requested documentation is not submitted with this application, and I do not reply to any of D&SDT-Headmaster's *emailed requests within one (1) month of submitting my application, my application will be denied and I will need to resubmit a new application and repay the fee.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.

Application Fee $25.00

Non-Refundable. All fees are non-refundable.

Cardholder Name

Card Number

Exp Month

Exp Year

Security Code

Cardholder Address

City

State

Zip Code