Nursing Student Application To Become An Illinois Certified Nurse Aide (Cna)
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1
2State of Illinois
Illinois Department of Public Health
Nursing Student Application to Become an Illinois Certified Nurse Aide (CNA)
(
All information requested on this application must be provided before you will be evaluated.
Please type or print legibly)
Today’s Date
Name
(First, Full Middle and Last)
Address
(Street, Apartment #, P. O. Box)
(City, State, ZIP Code)
Telephone_________________________________
Social Security Number
(required)
State(s) where you have been certified as a CNA
Name used when certified
If your current name is different from the name you used when you were certified, please attach a copy of the legal document(s) used to
change your name (i.e. marriage certificate, divorce decree, etc.) and a copy of your driver’s license or other picture identification.
Maiden name or other names you have been known by
Other states where you have lived or worked
I understand that the information requested regarding sex, race, height, eye color and date of birth is for the sole purpose of
identification and gathering the background check information. This information will not be used to discriminate against me in
violation of the law.
Male
Female Race
Height
Eye Color
Date of Birth
(Enter a letter from below)
A
Chinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander
B
Black or African American (Not Hispanic or Latino)
H
Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin)
I
American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states
of the United States or Alaska who maintains cultural identification through tribal affiliation or community recognition.
U
Of undetermined race or of untold mixture
W
Caucasian (not Hispanic or Latino)
Have you ever had an administrative finding of abuse, neglect or theft?
Yes
No
If “yes,” indicate in what state this finding was issued
PHOTOCOPIES OF THE FOLLOWING DOCUMENTS MUST BE ATTACHED TO THIS FORM
Are you a U.S. citizen?
Yes
No
(
If no, attach proof of employment authorization, such as a copy of
•
your Resident Alien Card, U.S. Visa, or form I-94)
This section to be completed by a nursing school official and stamped with the school’s seal. (
Please type
or print legibly)
Name of Nursing School
Address
The above named student
IS or WAS enrolled in an accredited
LPN or RN course at this school
(please circle one)
(please circle one)
and has successfully completed the fundamentals of nursing,
, on
, and
(course number)
___________________ (date)
successfully completed at least 40 contact hours of supervised clinicals on
____________________ (date).
Name of School Official
Telephone
Title
Signature
Date
Health Care Worker Registry, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761 • Phone 217-785-5133
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