State of Hawaii, Department of Commerce and Consumer Affairs

STATE OF HAWAII, DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS NURSE AIDE TESTING APPLICATION FORM (7/05)

Complete all items on this application. Please print.

1. Social Security Number: ______- ______- ______

2. Name: ______Last First Middle Initial

3. Current Address: ______Street, PO Box, RR ______City State Zip Phone #, Home Phone #, Work or Other

4. Gender (optional, check one) ___ Male ___ Female

5. Name of Nursing (Long-Term Care Employer) Facility if currently employed as a Nurse Aide ______Date Hired: ______

6. Name of Training Program attended: ______Total Hours: _____ (Submit copy of Completion Certificate of your DHS State-Approved CNA Training Program)

7. Date completed (or to be completing) training program: ______

8. Complete all of the following questions by answering Yes or No. Circle your answer a. Are you at least 18 years old?…………………………………… YES NO b. In the past 20 years, have you ever been convicted of a crime for which the conviction has not been annulled or expunged?………… YES NO c. Has your nurse aide certification ever been revoked, suspended, or otherwise subject to disciplinary action by another state registry? YES NO d. Are you presently being investigated or is any disciplinary action pending against you?……………………………………….. YES NO

If you answered “YES” to the above questions b thru d, please explain (date, place, nature of violation, etc.). Your application may be subject to Department Review, and certified documents relating to your case may be requested. ______9. Are you (check one) U.S. Citizen ___ U.S. National ___ An alien authorized to work in U.S. ___

I hereby certify that the information supplied herein is true to the best of my knowledge. I understand that my misrepresentation may be grounds for refusal or subsequent revocation of certification. (Section 710-1017 Hawaii Revised Statutes.)

______Signature of Applicant Date Test date requested

For Office Use: Cert. #______Initial Cert. Date ______Expiration Date:______