Submit New Application

Request to Become Employer in TMU© Application

Please complete this application to be listed as an employer in TMU© as an eligible employer to verify the employment of nurse aides for the renewal of their certification.

For a facility to be entered into the system as an employer, it must meet the following criteria:

Nurse aides performed nursing or nursing-related services for pay
Nurse aides are under the supervision of an RN or LPN
Approved by the Department of Human Services

Name

Phone

Alt Phone

Administrator

Medicaid Number

Address

City

State

Zipcode

Mailing Address

Address

City

State

Zipcode

Additional Information

Please list the job duties certified nurse aides perform at your facility

Additional Comments

Affidavit

I attest, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in denial of licensure.

By Submitting

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

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