RTC Certified Nurse Assistant (CNA) Examination Application

Applicant Information

Legal First Name*

Legal Last Name*

Middle Name

Social Security Number (SSN) or Tax-Identification Number (ITIN)* (omit dashes)

Confirm SSN / ITIN

Birthdate*

Gender*

Do you need any testing accommodations per ADA?

Yes

Accommodations - You must provide current documentation of a verified disability

Accommodation Requested (Please check all that apply)

Reason for Accommodation Request

DOCUMENTATION REQUIREMENTS FOR VERIFICATION OF DISABILITY

To receive services at a Regional Testing Center (RTC) test site location, an applicant must upload current documentation of a verified disability (including educational limitations and recommended accommodations) during the RTC application process.

Documentation of Physical/Mobility and Mental/Psychological Disability should be dated within 90 days of the request. All other disability documentation should be dated within 3 years of the request. Students with an Individualized Education Plan (IEP) must submit their most recent IEP and/or Multidisciplinary Report.

Please provide required disability documentation

I acknowledge that I uploaded the required disability documentation and that my RTC application and accommodation request may take up to 30 days to be reviewed. Sign language Interpreter request may take up to 60 days. Accommodation requests may not be available at all testing locations.

I acknowledge these terms.

Applicant Contact Information

Email Address*

Confirm Email Address

Type of Phone*

Phone Number*

Mailing Address*

Country

Street

City

Region

Postal Code

Qualification/Approval Information

Since completing the Certified Nurse Assistant (CNA) program or receiving the CDPH letter, indicate what attempt this exam will be in taking the CNA Examination:

First Attempt

Second Attempt

Third Attempt

Fourth or more attempt

The California Department of Public Health only allows 3 attempts per CDPH approval letter or with 2 years of completing a CNA Training Course.

If this is your fourth or more attempt in taking the CNA exam since completing your CNA training or receiving your CDPH letter, you will be automatically denied.

Name of CNA School/Training Facility or select "CDPH Approval Letter" *

Training Program Code or CDPH Approval/Sponsor Code*
(If entering a program code, add an S in front: S####)

Course Completion Date or California Department of Public Health (CDPH) Approval Date*

Note: You are required to pass both manual skills and written exam for CNA certification issued by the California Department of Public Health.
Rescheduling fees are required for all rescheduled, cancelled or missed exams.

Select Exam Type*

Terms of Application

Registration forms and testing fees must be received within 7 days of test date. No refunds will be issued once registration is processed.
The Regional Testing Center is not responsible for late, missing or lost applications.

Notification emails will be sent to confirming your registration request.
Once approved, a notification email will be sent to allow you to select a test location, date and time, and process payment.
A final confirmation email will be sent. You will need this email to enter the testing site.

On the day of the exam you must bring:
• Non-expired government issued photo identification
• A copy of your registration confirmation email with the application number
• Note: Failure to bring any of the above documents will prevent you from testing

By signing this form via electronic signature, I declare that the information I have provided is true and accurate to the best of my knowledge. I understand that any false information or misrepresentation of facts may cause invalidation of my testing results.
I understand that my name must be exactly the same on the registration application, my social security card, my government issued photo identification, and my CNA/HHA Initial Application (283B) or CDPH 932 approval letter. If the names do not match on all three items, I will not be approved for the CNA examination.

I authorize Regional Testing Center to release my evaluation results if requested by any agency that is authorized to receive this information and to use my evaluation results for research purposes.
I have read and agree to the terms of this application.

Signature*

Social Security or ITIN Card*

CNA Initial Application (283 B Form) or CDPH Approval Letter (932 form)
*Please include all pages*

Additional Page 2

Non-expired Government Issued Photo Identification*
Example: Driver's License

Other