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RN Test Observer | Test Administration Services Entity (TASE) Agreement Application

Please fill out this application and attach the following documentation:

An updated resume detailing your one-year experience providing care for the elderly or chronically ill of any age.
A copy of your RN Nursing License
W-9 (with your business name and your Federal Tax ID number on it - remember to sign it; there has to be a wet signature.) Click here to open the W-9 form
Direct Deposit Form, must include a voided check or bank letter (to electronically process successfully completed testing payments from Headmaster to you). Click here to open the Direct Deposit Form.
- Note this does not have to be a business bank account. We can electronically deposit your testing payments into any bank account.

There is a one-time fee of fifty dollars ($50.00) to certify that you have the necessary qualifications to administer exams that meet State testing standards. Please complete the credit/debit card certification fee payment information when you submit this application.

You will attest in the Affidavit at the end of this document that you have read, understand, and will abide by the following documents. Please print these documents and keep them for your records.

Click to open: TEST ADMINISTRATION SERVICES (TASE) AGREEMENT (1505MT-MA TASE)

Once you have completed all the fields and uploaded the required documents within this application, select “Send Application" to submit your application.

Legal First Name

Middle

Legal Last Name

Suffix

Birthdate

Phone

Address

City

State

Zipcode

RN License Information

License Number

Expires

Image of RN License

WORK EXPERIENCE VERIFICATION

Supervisor's Name Name of supervisor that will verify your one-year work experience providing care for the elderly or chronically ill of any age.

Facility Name

Facility Address

Facility City

Facility State

Facility Zip Code

REFERENCE

Reference's Name Name of reference that will certify the herein disclosed information is true and correct.

Reference's Email

Reference's Phone Number

RESUME

Resume Please upload your resume detailing your one-year work experience providing care for the elderly or chronically ill of any age.

TEST ADMINISTRATIONS SERVICES ENTITY (TASE)

TASE Testing Administration Services Business Name (Please complete the following fields for your Testing Administration Services Business Entity (TASE).

TASE Federal Identification Number (FEIN).

TASE Secretary of State ID #.

TASE Contact Name (if different than RN Test Observer name), if applicable.

TASE Phone # (if different than RN Test Observer phone number), if applicable.

TASE Address (if different than RN Test Observer address), if applicable.

TASE City (if different than RN Test Observer city), if applicable.

TASE State (if different than RN Test Observer state), if applicable.

TASE ZIP Code (if different than RN Test Observer ZIP code), if applicable.

TASE Email (if different than RN Test Observer email), if applicable.

TASE Website (optional)

IRS FORM W-9 (Request for Taxpayer Information)

IRS Form W-9 (must have your business name and your Federal Tax ID number on it and must be signed-there has to be a wet signature). If applicable, please complete the IRS W-9 form (link found in the directions and affidavit) and upload it with this application.

DIRECT DEPOSIT FORM

Direct Deposit Form (must include a voided check or bank letter). If applicable, please complete the Direct Deposit Form (link found in the instructions and affidavit) and upload it with this document.

STATE OF MONTANA INDEPENDENT CONTRACTOR EXEMPTION CERTIFICATE (ICEC) IF APPLICABLE

State of Montana Independent Contractor Exemption Certificate (ICEC), if applicable If applicable, please upload your approved State of Montana ICEC certificate.

Affidavit

CONFIDENTIALITY/NONDISCLOSURE:
I acknowledge the confidential nature of the Medication Aide I & II competency examination, including the materials, processes, procedures, and content of the knowledge exam.

I agree to safeguard the confidentiality of all information about the medication aide I & II competency examinations.
I will not disclose any portion of the examination materials.
I will not disclose the processes or procedures necessary to administer or pass the examination.
I will not disclose any examination results to instructors or administrators of any training facility or program.
I will not test or be involved in testing students I have trained, family members, or close personal friends.

I understand that this agreement extends to and includes, but is not limited to, allowing unauthorized persons to hear, view, videotape, or otherwise gain any knowledge about the exam before, during, or after the administration of an exam. I recognize that disclosing or revealing, or allowing this information to be disclosed or revealed, constitutes a violation of this agreement and could place my nursing license at risk and/or be subject to prosecution to the full extent of the law and/or a $100,000 fine. I agree to immediately report any known or suspected breach in security relative to the Medication Aide I & II competency examination by calling the D&SDT-HEADMASTER home office at (800)393-8664.

TEST ADMINISTRATION SERVICES (TASE) AGREEMENT (1505MT-MA TASE): (Keep a copy of this agreement for your records.) Click on the 1505MT-MA TASE AGREEMENT FORM to open the document.
I hereby certify that I have read, understand, and will abide by the terms and conditions of the Testing Services Business Entity Agreement Form (1505MT-MA TASE) as established to do business by statute in the State of Montana.

I understand that there is a one-time fee of fifty dollars ($50.00) to certify that I have the necessary qualifications to administer exams that meet State testing standards.

I have uploaded the required documentation with this application, which includes:

Resume and copy of my RN License

If applicable, I have also uploaded:

Signed (with a wet signature) W-9 Form with my business name and Federal Tax ID
Direct Deposit Form with a voided check or bank letter
My approved State of Montana Independent Contractor Exemption Certificate (ICEC)

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 $50.00

Non-Refundable. All fees are non-refundable.

Cardholder Name

Card Number

Exp Month

Exp Year

Security Code

Cardholder Address

City

State

Zip Code