NRRTS Renewal Application 2

Today's Date*

Gender*

Male
Female

How do you want to receive DIRECTIONS?*

Print
Digital

I understand that as a NRRTS Registrant I will receive periodic, non-marketing digital notifications directly from NRRTS.*

Yes

What Year Were You Born?*

YEAR only

Name*

First Last

First Name You Go By*

Business Name*

Preferred Mailing Address*

Business
Home

Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone*

Preferred Email*

Alternate Email*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone*

Do you have your ATP?*

Yes
No

ATP Expiration Date

Do you have your SMS?*

Yes
No

Did you complete your education with NRRTS?*

If you completed your education with NRRTS, you do not need to upload education. We have your education on file.

Yes
No

Upload non-NRRTS CEUs & Business Card

Drop files here or

Max. file size: 50 MB.

Affirmation of Good Moral Character

We require that you answer the following questions that address issues that may be harmful to the public or inappropriate to the profession. A “yes” answer will not necessarily result in a denial of registration or renewal. However, failure to fully disclose any relevant information will be considered grounds for denial of Registration or renewal. No applicant or registrant will be denied registration or renewal solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense will be considered. This includes any expunged records in any legal jurisdiction.

1. Have you ever been found guilty of, pled guilty or no contest to, entered into a plea agreement instead of prosecution, or found guilty without conviction (adjudication withheld) on a felony charge in any legal jurisdiction? Failure to disclose any relevant information will be considered grounds for denial*

Yes
No

2. Have you ever been found guilty of, pled guilty or no contest to, entered into a plea agreement instead of prosecution, or found guilty without conviction (adjudication withheld) on a misdemeanor involving theft, fraud, bribery, corruption, perjury, embezzlement, solicitation, dishonesty, physical harm or threat of physical harm to the person or property of another or substance abuse in any legal jurisdiction?*

Yes
No

3. Have you ever been subject to an adverse civil or administrative judgment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or any offense that calls into question the integrity or judgment of your actions?*

Yes
No

4. Are you currently or ever been subject to sanction, reprimand, suspension, or restriction by any governmental agency, professional body, association, licensing authority, board or certifying association of which you were or are a member or subject to its jurisdiction?*

Yes
No

5. Have you ever been discharged from employment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or any offense that calls into question the integrity or judgment of your actions?*

Yes
No

If you answers "Yes" to any section, please provide details

Registrant Signature*

By signing below you affirm that your answers to the above questions are true and that you agree to abide by the NRRTS Code of Ethics; Standards of Practice and Blind Bidding Policy. If any sections have a “YES” answer, provide all details below. This will be kept confidential.

WORK EXPERIENCE VERIFICATION - MUST BE SIGNED BY A SUPERVISOR/MANAGER

NRRTS will obtain your supervisor's signature on your behalf if your supervisor is not immediately available. Please complete the information.

Supervisor's Name*

First Last

Supervisor Title*

Supervisor's Email*

Supervisor's Phone*

Does the registrant have supervisory or management responsibility?*

Yes
No

What % of his/her time is spent on patient care and service delivery?*

A background check has been performed on this employee*

Yes
No

Restriction of employment resulted from Background check*

Yes
No

If YES, provide Detail with dates and restrictions noted below. This will be kept confidential.*

Supervisor's Signature

This should be signed by a supervisor. If your supervisor is not available, NRRTS will obtain the signature.

Phone

This field is for validation purposes and should be left unchanged.