Initial Medication Assistant I & Ii Application - North Dakota Department Of Health Page 2
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1
2Medication Assistant Training Program
Name of Medication Assistant Training Program
Address
City
State
Zip Code
Date of Enrollment
Date of Completion
Registered Nurse Instructor/Program Supervisor
Name
Registered Nurse Number
E-mail Address
Phone Number
Signature
Date
NOTE: Please attach a copy of a Certification of Completion and/or a Class Roster or letter demonstrating
successful completion of an approved Medication I or II Training Program.
Please remit $25 (
) Non-refundable Fee
U.S. dollars
Make checks and/or money orders payable to the North Dakota Department of Health.
All completed forms and checks or money orders must be sent or delivered together to:
North Dakota Department of Health
Division of Accounting
600 East Boulevard Ave., Dept. 301
Bismarck, ND 58505-0200
If you have questions or wish to contact the Department of Health, please phone 701.328.2353 or contact us by
e-mail at
naregistry@nd.gov
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