Cna Recertification Application Form printable pdf download

Professional Healthcare Educators

1286 Kalani St. B-204, Honolulu, Hawaii 96817 / Tel:(808)847-3366

CNA RECERTIFICATION APPLICATION FORM

Course Title: CNA Competency/Proficiency Evaluation

Approved and Certified by the State of Hawaii Department of Human Services,

Med-Quest Division

Student: Last __________________________________ First: ________________________________ MI ______

(PRINT ONLY PLEASE)

Address: ___________________________City:_________________ State: _____________Zip Code: __________

Cell/Other: (

) _____________________________ Email: _______________________________________

How did you find us? Friend/Family: _____Website: _____Other: ________Last 4 digit SS #: ___ ___ ___ ___

CNA License #:HI- ____ ____ ____ ____ ____ ____ ____ ____ ____ Exp.Date:______/______/_______

Month

Date

Year

$125.00

FEE:

Course Description: 24hrs lecture/discussion/clinical at Professional Healthcare Educators

Requirements:

1. Copy of current CNA certificate

2. Employed as a CNA in a State Approved Facility (at least 8 hours) and verified by qualifying

employer to get recertified

3. Photo identification

4. Last 4 digits of Social Security number

Payment Policy: Tuition and/or fees must be paid in full at time of registration. All forms of payment accepted

(cash, certified check, credit & debit cards). Make checks payable to Professional Healthcare Educators.

An additional fee of 6% will be charged using credit or debit card.

Agreement is binding:

This agreement will be binding only when it has been fully completed, signed and dated by the student and an

authorized representative of the school prior to the time instruction begins.

Changes in the agreement:

Any changes in the agreement will not be binding on either the student or the school unless such changes are

acknowledged in writing by an authorized representative of the school and by the student. We reserve the right

to cancel classes for any reason or postpone classes due to insufficient enrollment. Every effort will be made to

notify you of a cancelled class well in advance. If we cancel a class you will receive a full refund of the class fee.

In the event that you decide to cancel, a full refund may be given if a written or personal cancellation is received

at least 3 working days prior to start of class. No refund granted after.

Effective date of acceptance:

I hereby agree to abide by the conditions set forth herein. I declare that I am 18 years of age or older,

a high school graduate, and of no criminal record.

Signature: _______________________________________________ Date: ___________________________

--------------------------------------------------------------------------------------------- ------------------------------------------------------

Office use only:

School representative: __________________________________

Date: ______________________________

Cna Recertification Application Form

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