Account Applications Create

Request to Become Employer in TMU© Application

Please complete this application to be listed as an employer in TMU© as an eligible employer to verify the employment of nurse aides for the renewal of their federal certification.

In the Name field please enter the operating name of the facility or entity.

The email address you enter will be the email which receives notification of pending verification requests. This email can only be associated with a single facility or entity. Please consider using a general email such as "hr@entityexample.org", to ensure continuity despite staffing changes.

For a facility to be entered into the system as an employer, it must meet the following criteria:

Nurse aides performed nursing or nursing-related services for pay
Nurse aides are under the supervision of an RN or LPN

Name

Phone

Administrator

Medicaid Number

Address

City

State

Zipcode

Mailing Address

Address

City

State

Zipcode

Additional Facility Information

Discipline Select the discipline type you are applying for.

Employer Type

Choose employer type

If employer type is other, upload a job description Upload a copy of the job description for nurse aides in your employment setting

RN/LPN Supervision

Name of Nurse

License Number

License Type

License Number

Affidavit

I attest, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in denial of licensure, a fine of up to $10,000, or imprisonment not to exceed six years or both (Wis. Stat. § 946.32).

By Submitting

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