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Clinical Teaching Associate Application 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.

LPN applicant: Submit a signed Guidelines for LPN CTA of an NA/MA Education Program (Form EDU-736). Located on the OSBN website: Form_EDU-736.pdf

Legal First Name

Middle

Legal Last Name

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Phone

Gender

Male Female Other

Address

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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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Guidelines for LPN CTA if needed Guidelines for LPN CTA of an NA/MA Education Program (Form EDU-736).

Resume Upload a current resume

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.