Maine Registry Of Certified Nursing Assistants (Cna) Application For Cna
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2STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF LICENSING AND REGULATORY SERVICES
-
Maine Registry of Certified Nursing Assistants (CNA)
Application for CNA
SECTION 1: Applicant Information
Legal Name (First, Middle, Last):
Previous Name(s):
Social Security Number:
Date of Birth:
Mailing Address:
City:
State:
Zip:
County:
Email Address:
Telephone No.: (
)
SECTION 2: Application Type
APPLICATION FOR CNA
Please check one:
New Application
Inactive – applying for reinstatement
Please select the type of application:
Application for a CNA trained in the State of Maine
Application for a CNA trained in another State/Jurisdiction
Military
(Must submit DD-214 Form or military equivalent)
Student Nurse, enter location: ________________
(Must submit letter or certificate demonstrating equivalent training)
Current Registered Nurse
(Must submit copy of current RN or LPN license)
For questions regarding this program and/or application, please contact the following:
Department of Health and Human Services
Licensing and Regulatory Services
Maine Registry of Certified Nursing Assistants (CNA)
41 Anthony Ave; 11 State House Station
Augusta, ME 04333-0011
Tel: (207) 624-7300
Fax: (207) 287-9325
Toll Free: 1-800-791-4080
TTY users call Maine relay 711
Email:
dlrs.cnaregistry@maine.gov
Office Use Only:
License# ______________ Approved by: _________ Approved Date: _________
Page 1 of 2
Form 060101 Rev 1/2014
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