Account Applications Create

OK MA/MA-IA: Knowledge Test Proctor | Test Administration Services Entity (TASE) Application

Please fill out this application and attach the following documentation:

NOTE: The RN LICENSE INFORMATION is not required unless you are an RN. In that case, please provide your license number, expiration date, and an image of your license.

Resume
W-9 (with your business name and 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 1505OK MA/MA-IA

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

SSN

Gender

Male Female Other

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 work experience.

Facility Name Name of the supervisor's facility.

Facility Address

Facility City

Facility State

Facility Zip Code

Facility Phone Number

REFERENCE

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

Reference's Email

Reference's Phone Number

RESUME

Resume Please upload your resume detailing your work experience.

TEST ADMINISTRATION 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/KTP name)

TASE Phone # (if different than RN Test Observer/KTP phone number)

TASE Address (if different than RN Test Observer/KTP address)

TASE City (if different than RN Test Observer/KTP city)

TASE State (if different than RN Test Observer/KTP state)

TASE ZIP Code (if different than RN Test Observer/KTP ZIP code)

TASE Email (if different than RN Test Observer/KTP email)

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

DIRECT DEPOSIT FORM

Direct Deposit Form (must include a voided check or bank letter) Please complete the Direct Deposit Form (link found in the instructions and affidavit) and upload it with this document. Direct Deposit Form must include a voided check or bank letter. NOTE: This does not have to be a business bank account, we can electronically deposit your testing payments into any bank account.

Affidavit

CONFIDENTIALITY/NONDISCLOSURE:
I acknowledge the confidential nature of the Medication Aide and MA-Insulin Administration Competency Exam, including the materials, processes, procedures, and content of the knowledge portion.

I agree to safeguard the confidentiality of all information about the competency examination.
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 or had professional contact with during training, family members, or close personal friends.
If I am a Director of Nursing, I am not eligible to be a Knowledge Test Proctor.

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 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 and MA-insulin administration competency examination by calling the D&SDT-HEADMASTER home office at (800)393-8664.

EXPECTATIONS: I understand I will be administering Oklahoma competency testing for Medication Aide/MA-Insulin Administration knowledge exams at D&SDT-HEADMASTER/Oklahoma State Department of Health (OSDH)-approved test sites. I will ensure that all necessary materials and equipment are available for the consistent administration of the competency exam testing.

TEST ADMINISTRATION SERVICES (TASE) AGREEMENT (1505OK MA/MA-IA): (Keep a copy of this agreement for your records.) Click on the 1505OK MA/MA-IA 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 (1505 TASE) as established by statute in the State of Oklahoma to do business.

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:

NOTE: The RN LICENSE INFORMATION is not required unless you are an RN. In that case, please provide an Image of your RN License.
Resume
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

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 $100.00

Non-Refundable. All fees are non-refundable.

Cardholder Name

Card Number

Exp Month

Exp Year

Security Code

Cardholder Address

City

State

Zip Code