RTC Certified Nurse Assistant (CNA) Examination Application

This RTC CNA Examination Application only needs to be completed ONCE for each applicant. If you have submitted this form before and it has been approved, please login to the RTC Portal to register for an exam.

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

By selecting Yes, you will need to upload your required disability documentation prior to submitting your RTC application. For a list of Documentation Requirements for Verification of Disability please click here

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.

Please refer to your CNA Initial Application (CDPH 283B form) to obtain your “California Training Program ID number for CNA” and Name of school or facility where you received the CNA training.

Your Certified Nurse Assistant Competency Evaluation Approval letter (CDPH 932 form) to obtain the Sponsor ID: number that is required when selecting the drop down menu below.

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

Please enter in the box below, the Training Program ID number (238B form) or Sponsor ID number (932 form).

This ID number needs to match the number that was selected in the drop down menu above.”

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.

Terms of RTC CNA Examination Application

This RTC CNA Examination Application only needs to be completed ONCE for each applicant and will be reviewed in the order it’s been received. Once your application has been submitted, you will receive an email notification within 3-4 business days.

Once an application has been reviewed, an approval or denial email notification will be sent out. A CNA Exam Registration Approval email is sent to applicants who successfully completed their RTC application and are provided instructions on how to activate their RTC account and register for an exam.

The Regional Testing Center is not responsible for technical issues encountered during the online application process (including security settings that may affect the software from running correctly). NO REFUNDS will be issued once exam registration fees have been processed.

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 required documents, my RTC application will not be approved for the CNA examination.

I authorize the Regional Testing Center to release my CNA exam results if requested by any agency that is authorized to receive this information and to use my exam results for research purposes.

I have read and agree to the terms of this RTC CNA 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