Submit New Application

TN Reciprocity Form 9110 Application

NOTE: Please do not use this system for renewing your nurse aide certification in Tennessee. 

For information regarding a renewal - click here 

DO NOT COMPLETE THIS FORM if you have ever been listed on the Tennessee Nurse Aide Registry. Contact the TN Registry at (615)532-5171 or click here to verify your status. 

Please read these directions before you complete and submit this form. Your request for reciprocity cannot be processed if it is incomplete, illegible, or includes false statements. Candidates seeking out-of-state nurse aide registry placement must be in good standing on a nurse aide registry in a state that meets the Tennessee requirements for reciprocity to be eligible for certification in Tennessee.
 
[NOTE FOR INDIVIDUALS CERTIFIED IN FLORIDA: Individuals certified in Florida must complete an approved Tennessee Nurse Aide Training Program and pass the Tennessee Competency Evaluation process. (Train at an approved Tennessee nurse aide training program and pass the approved Tennessee nurse aide competency test.)] 

Complete this form, 9110TN. Attach the required identification documents (see below). Pay the non-refundable reciprocity verification and processing administrative assessment fee of $25 through the secure credit card processing portal. 

Please note, completing this form requires the following attachments: 
  1. Image of your social security card 
  2. Image of your valid US government-issued photo identification (state driver’s license, passport, or other signed current, photo identification). 
Your name will be placed on the registry if you are qualified after the following is successfully completed: 
  • We verify your certification (in good standing) with the state(s) where you are currently registered. 
  • The Tennessee nurse aide registry verifies you are eligible for placement on the registry. 
  • All other provided and pertinent information is verified as true and correct. Notification of successful submission for TN registry placement will be emailed to the email address in your application. 
Your application is not complete until the required information is included, then select “Send Application.”
Demographics
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in
Address
Reciprocity Information
Required Questions
Images of the following documents must be included.
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.
1.800.393.8664