Printable Certification Program Application (CNA and HCA)
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Train to become Certified (CNA or HCA)

These state approved program completes classroom work in 10-12 weeks.  Some students have additional clinical hours, to be arranged with the clinical instructor. Clinical hours may begin as early as the 5th week of the program. Upon completion you are eligible to take the state exam for certification. While employment is not guaranteed, placement assistance is available.

How to get started:

1.      Attend an informational meeting. There is no cost and no obligation. This meeting last about an hour and explains in detail what options are available.


2.    Complete an application packet. Pick up an application packet or print this age. Deliver the completed packet with the background check fee of $25 (non-refundable). Once accepted, the application packet is good for 6 months.

3. Make your tuition payment. This can be by cash, check, money order, or credit card.  Payment arrangements and the mandatory Federal Tuition Reimbursement program are discussed at the informational meeting

4. When the application process is complete, you will be schedule for the next available class.

5. Attend the first class. Bring only a notebook, pen and dress comfortably. Fees will be discussed at the informational meeting.

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Submit this application with $25 background check fee. This fee is non-refundable. Acceptance is not guaranteed until application is processed.

Personal Information

Name:____________ Phone:

Present Address:_______________________________________________

Former Address is less than 5 years:____________________________

Cell Phone_______________________________ Email:__________________

Driver's State:________

Social Security no:__________ Birth Date:

Former Employers (Last two employers or last 5 years):

Name Address Phone Dates

1.___________________________________________________________________________

2.___________________________________________________________________________

3.___________________________________________________________________________

4.___________________________________________________________________________

Education:

High School:___________________________________________________

College:______________________________________________________

Other training programs:_________________________________________

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GENERAL

Subjects of special study, research work or certifications/licenses:

Former CNA____________ CNA in other state_______________ current RNA______________

Acceptance is contingent upon background check, investigation of former employment, and confirmation of identify. If I am offered a place in the program, I agree to submit to a medical examination and drug test at any time deemed appropriate by the company and as permitted by law; results remain confidential. I certify that the information contained in this application and all accompanying documentation is true and complete to the best of my knowledge and that any omission, false statement, or misrepresentation is cause for dismissal no matter when discovered by the company. I agree to abide by all company rules and policies. The company retains the right to revise policy at any time.

Date:________________Signature:____________________________________________________________

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