Form Doh 667-034 - Nursing Assistant Expired Certification Activation Application Page 5
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Nursing Assistant Certified Credentialing
Stamp
P.O. Box 1099
Olympia, WA 98507-1099
Here
Revenue IF 0299030000 --56-
Nursing Assistant Expired
Certified Activation Application
Please print clearly. Follow the instructions provided. It is the responsibility of the applicant to submit or request all
required supporting documents be submitted. Failure to do so may result in a delay in processing your application.
1. Demographic Information
Social Security Number
(SSN)
National Provider Identifier Number
(NPI)
F Male
(If you do not have a SSN, see instructions)
(Enter 10 digit number)
F Female
Name
First
Middle
Last
Place of birth
Birth date (mm/dd/yyyy)
City
State
Country
Address
City
State
Zip Code
County
Country
Phone (enter 10 digit #)
Fax (enter 10 digit #)
Cell (enter 10 digit #)
Email address
Mailing address if different from above address of record
City
State
Zip Code
County
Country
Note: The mailing and email addresses you provide will be your addresses of record. It is your
responsibility to maintain current contact information on file with the department.
Have you ever been known under any other name(s)? F Yes F No If yes, list name(s):
Will documents be received in another name? F Yes
F No If yes, list name(s):
DOH 667-034 September 2016
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