Interstate Application Form printable pdf download

KANSAS DEPARTMENT

INTERSTATE APPLICATION

complete this form if you have previously been a Certified Nurse Aide in Kansas. You may contact the

Please Note: DO NOT

Kansas Nurse Aide Registry at 785-296-6877 for your Kansas certification status.

In order to be eligible to sit for the Kansas Nurse Aide Test, the candidate must be listed as current or active on any other State’s

registry. Any potential candidate who is not sure of his/her status is advised to contact their State registry prior to applying for Kansas

certification at

Candidates For Testing Must Complete This Form And Attach The Following:

 Copy of identification with current name and social security number (drivers license, social security card, picture ID)

 Non-refundable application fee of $20.00 (Check, money order or certified check)

Name _____________________________________________________________________________________________________

List all OTHER Names: (MAIDEN/SURNAME)

LAST

FIRST

Social Security Number # __ __ __ - __ __ - __ __ __ __ Birth Date ______/______/______ Male

Female

Home Address ______________________________________________________________________________________________

STREET

CITY

STATE

ZIP

Phone Number: Home (_____) _________________ Work: (_____) __________________ Cell: (_____) ___________________

Please Mark The Highest Level Of Education Completed:

____ No High School Diploma or GED

____ Diploma RN

____ Master’s Degree

____ High School Diploma or GED

____ Associate Degree

____ Education Specialist

____ Licensed Practical Nurse (LPN)

____ Bachelor’s Degree

____ PhD

Certification Information:

Original Certificate # ______________ Issued by State of ______ Date Issued ___/___/___ Certificate Expiration Date ___/___/__

Check Test Site Preference:

____ Atchison

____ Concordia

____ Great Bend

____ Kansas City, ATS

____ Merriam

____ Salina

____ Beloit

____ Dodge City

____ Hays

____ Kansas City CC

____ Overland Park

____ Topeka

____ Burlingame

____ El Dorado

____ Hutchinson

____ KC Donnelly

____ Pittsburg

____ Wichita

____ Chanute

____ Emporia

____ Independence, Ks

____ Liberal

____ Parsons

____ Winfield

____ Coffeyville

____ Fort Scott

____ Iola

____ Manhattan

____ Pratt

____ Colby

____ Garden City

____ Junction City

Candidate's Signature:

I do hereby attest that the information supplied in this application and any attachments is accurate and complete to the best of my

knowledge. I do hereby give permission to the department to verify any information provided in this application and any attachments.

Attached is my $20.00 certification application fee and copy of identification with my current name and social security number (SS-

Card, Drivers license, W-2).

_____________________________________________________________________

___________________________________

Candidates Signature

Date

Email Address

Please return this form and attachments to:

Kansas Department for Aging and Disability Services (KDADS), Health Occupations Credentialing (HOC)

612 S Kansas Ave, Topeka, KS 66603-3404

ONLY: Approval Date:

Test Date:

Revised 08/04/2014

Interstate Application Form

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