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 Federal 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

Name

Phone

Administrator

Approval Number

Medicaid Number

Address

City

State

Zipcode

Mailing Address

Address

City

State

Zipcode

Additional Facility Information

Facility Name Provide name of the employment facility

Discipline Select the discipline type you are applying for.

Parent Facility Select the parent facility for this facility.

Employer Type

Choose Employer Type

If employer type is other, upload a job description. Upload a copy of the job description for nurse aides in your employment setting.

Affidavit

I attest, under penalty of law, that the information provided 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.