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Clinical Teaching Associate Application

Clinical Teaching Associate (CTA) Applicant must:

Hold a current Oregon RN or LPN license; and
Have the equivalent of at least one year of experience as a licensed nurse.

Legal First Name

Middle

Legal Last Name

Suffix

Phone

Gender

Male Female Other

Address

City

State

Zipcode

RN License Information

License Number

Expires

Education Program Information

Program Name Program Name

Program Type Select the program type you are applying for. If you are applying for both NA and MA programs, please write a comment to let OSBN know. *For MA CTA: must have six months' nursing experience in a facility licensed the same as the setting in which the medication aide student will be passing medications.

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Comment

Comment If you are applying for both NA and MA programs, please write a comment to let OSBN staff know.

Affidavit

By Submitting

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