D&S Diversified Technologies dba HEADMASTER

150 Horse Shoe Bend Road Helena, MT 59602

406-442-8656 -- fax 3357 -- www.hdmaster.com

Providing CNA testing solutions throughout

Substitute ID Form

Section One

To be completed by Sponsoring Facility Representative prior to the Test Day. Please have the candidate give this form to the Test Administrator the day of testing. The Test Administrator will submit this form to HEADMASTER.

Please Print:

I, __________________________________, am authorized to complete this official substitute for State-issued photo identification to be presented to the Test Administrator at the Test Site on the Test Day listed below. This substitution is in full compliance with HEADMASTER Certified Nurse Aide Test regulations.

Candidate Name: __________________________________ Height: ____________ Weight: ____________

Eye Color: ______________ Hair Color: _______________ Race: _____________Age: ______ Sex: M / F

Test Site: _____________________________ Four Digit Site #: _________ Test Date: _____/_____/_____

Candidate Signature: _______________________________________________ Date: _____/_____/_____

I certify that the information above is complete and accurate, and that the Candidate has signed in my presence.

Sponsor Signature: ____________________________ Title: _______________ Date: _____/_____/_____

Section Two

To be completed by Test Administrator on Test Day.

I am the Candidate named and described above, and am signing this document in the presence of the Test Administrator.

Candidate Signature: _______________________________________________ Date: _____/_____/_____

Test Administrator Signature: _________________________________________ Date: _____/_____/_____

TA: Please return this document with all other test materials to HEADMASTER, 150 Horse Shoe Bend Road, Helena, MT 59602, upon the completion of the test.

Last Updated June 12, 2003