Maine Registry Of Certified Nursing Assistants (Cna) Application For Cna (Page 2 of 2) in pdf

SECTION 3: Applicant Background

Please answer the following questions:

*If you answer “Yes” to any question, you must attach an explanatory letter that includes the location and date of each

occurrence.

**If you answer “Yes” to questions 3, 4, 5, 6 or 7, you must attach court documents pertaining to each conviction.

☐ No ☐ Yes

1. Have you ever been denied a CNA certificate or license?

2. Have you ever had any disciplinary action (probation, suspension, revocation or

☐ No ☐ Yes

reprimand) taken against your CNA certificate or license?

☐ No ☐ Yes

3. Have you ever been convicted of any crime under the laws of Maine?

☐ No ☐ Yes

4. Have you ever been convicted of any crime under the laws of any other State?

☐ No ☐ Yes

5. Have you ever been convicted of any crime under the Federal laws of the United States?

☐ No ☐ Yes

6. Have you ever been convicted of any crime under the laws of any other country?

7. Have you ever been convicted of any crime that took place in any health care setting in

☐ No ☐ Yes

the State of Maine, or any other State?

SECTION 4: Submission

Submit your completed application, and the following additional information:

Copy of the applicant’s CNA training certificate. (No originals please)

Copy of the applicant’s Social Security Card. (No originals please)

Copy of the applicant’s current driver’s license (or official government I.D.) containing a photograph and signature.

(A valid passport is also acceptable) (A student I.D. is NOT acceptable) (No originals please)

Letters from employers (if applicable): Place(s) and date(s) of employment as a CNA within the last twenty-four (24)

months. (Officially documented by the employer in a letter to the Registry)

Copy of the criminal background report done at the time of your CNA training course. (Only necessary to submit this

with your first Registry application following completion of the course.) Please note: the criminal background check

must include a report on all names the applicant has held as an adult.

Applications for a CNA trained in a State other than Maine, please submit the following additional information:

Copy of documentation that the applicant’s CNA training is equivalent to or greater than Maine’s required hours of

classroom and clinical training. (No originals please)

Copy of documentation of a passing score on the CNA competency evaluation testing. (No originals please)

Copy of documentation of the applicant’s completion of at least the ninth (9

) grade of school. (No originals please)

Letters from employers (if applicable): Place(s), date(s), and number of hours worked while employed as a CNA

during the last 5 years. (Officially documented by the employer in a letter to the Registry.)

Failure to submit any of the required information will delay the processing of your application.

SECTION 5: Declaration

The Maine Registry of Certified Nursing Assistants (the “Registry”) shall deny any applicant, or a CNA, placement or

continued listing on the Registry if an application contains known misrepresentations, or represents in any way an

attempt by the applicant, or CNA, to obtain placement or continued listing on the Registry by deceitful or fraudulent

means.

I believe that all of my answers to the above questions are true and correct. I understand that the staff of the Registry

will verify the information on this application for its truthfulness and that knowingly making a false statement on this

application may subject me to prosecution under applicable Maine law.

_______________________________________ _____________________________________ ____________________

Print Name of Applicant

Signature of Applicant

Date

Page 2 of 2

Form 060101 Rev 1/2014

Maine Registry Of Certified Nursing Assistants (Cna) Application For Cna Page 2

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