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TEST SITE Application

Please complete this application to become an approved Caregiver and/or Manager Test Site.

NOTE: If you are applying to be both a Caregiver and a Manager test site:

Choose CAREGIVER under Discipline for your test site application, and then
Select 'YES' in the Assisted Living Facility Manager Test Site Request section.

In the Affidavit at the end of this document, you will attest that you have read, understood, and will abide by the following Test Site Agreement document. Please print the document and keep it for your records.

Click to Open: Test Site Agreement

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

Name

Fax

Phone

Alt Phone

Administrator

Address

City

State

Zipcode

Mailing Address

Address

City

State

Zipcode

Additional Facility Information

Discipline Select only one of the discipline types you are applying for. NOTE: IF YOU ARE APPLYING TO BE BOTH A CAREGIVER AND A MANAGER TEST SITE, please choose Caregiver as the discipline and then indicate in the Assisted Living Facility Manager Test Site Request below that you also will be a Manager test site.

Parent Facility Select the parent facility for this facility.

Assisted Living Facility Manager Test Site Please select YES above if you wish to also be a Manager test site.

Candidate Directions

Additional Directions: Candidates receive a confirmation letter with the address of your facility upon scheduling. If you have any additional directions for how to get there or where to go once they arrive, please provide that information here. (For example, landmarks to look for, parking lot to use, building number, entrance number, floor and room number, or any other directions that help candidates get to your test site.

Affidavit

TEST SITE AGREEMENT:

I hereby agree to and understand that our Facility will allow Assisted Living Facility Caregiver and/or Assisted Living Facility Manager tests to be administered under the guidelines in the Test Site Agreement.
I understand that if I apply to be both a Caregiver and a Manager Test Site, I have indicated 'YES' to be a Manager test site in the Assisted Living Facility Manager Test Site Request section.
I certify that our site is not under authoritative sanctions, and I have read, understood, and will abide by all listed guidelines in the Test Site Agreement.

By Submitting

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