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Certified Medication Aide Instructor Access Application

Legal First Name

Middle

Legal Last Name

Suffix

Birthdate

Phone

Gender

Male Female Other

Address

City

State

Zipcode

RN License Information

License Number

Expires

CMA Training Program Select the training program you are instructing

Are you already in the TMU system as a Nurse Aide Instructor?

FACILITY ADDRESS

CMA Training Program Affiliation Name of the facility that you are a CMA instructor.

ADDRESS

CITY

STATE

ZIP CODE

KBN CMA Program Approval Letter Please Upload the Approval letter from the KY Board of Nursing, allowing the facility to instruct Medication Aide courses.

AFFIDAVIT

I attest that by completing this application: I have met the requirements of a Certified Medication Aide instructor and can enter and certify completion of training of certified medication aide candidates. (201 KAR 20:700) BY SUBMITTING I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.

Full Name

Affidavit

By Submitting

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