Cna Renewal Application Form printable pdf download

CNA RENEWAL INSTRUCTIONS

A CERTIFICATE CAN BE ISSUED FASTER IF YOU RENEW ONLINE

You are encouraged to complete the application online. Online renewal will provide you with an easy, efficient and

safe way to renew your license 24 hours a day. Go to https://myservices.azbn.gov. A convenience fee of $3.00 is

charged for online renewal.

RENEWAL SCHEDULE: Certified Nursing Assistants (CNAs) are required to renew nursing assistant certification every 2 years by

the last day of the CNA’s birth month. It is the responsibility of the CNA to keep her/his addresses current with the Board.

RENEWAL REQUIREMENTS:

 Applicants must have worked, doing nursing assistant duties, for a minimum of 160 hours within the past 2 years.

LATE CERTIFICATION: Online Renewal is not available for expired certification. If you are renewing after your certification

has expired, a lapsed certificate questionnaire must be submitted with the renewal application. The Lapsed/Expired Certificate

Questionnaire is included in this packet. Fingerprinting is required only if your CNA certification has been expired for more than two

years. Please call the board for a fingerprint card to be sent to you.

PAPER APPLICATION FEES:

ALL FEES MUST BE IN US DOLLARS AND ARE NON REFUNDABLE

 You may pay by credit/debit card (must complete attached two pages for credit card authorization) or money order or check. All

personal checks must be pre-printed with your name and address and made payable to the Arizona State Board of Nursing.

 There is a $50.00 fee for all checks returned for insufficient funds.

 Late Fee: If you have worked as a CNA on an expired certificate, a $10.00 late fee per year you’ve worked will be charged. See

the Lapsed/Expired Certificate Questionnaire. A late fee is not needed if you have not worked on an expired CNA certificate.

 If your renewal is late, all fees submitted will be applied to the late fee before they can be applied to the document fee.

 Document Fee: The CNA document (a wallet size, pink colored paper certificate) is OPTIONAL. If you request an optional

document, the fee is $50. The document will only be issued when requested and when the fee is received. (See selection box on

renewal form.) IF FEE IS NOT INCLUDED, THE BOARD WILL ASSUME YOU DID NOT REQUEST A DOCUMENT.

 All mailing address changes are to be submitted to the Board within 30 days. If you are submitting an address change on the

application and it has been more than 30 days since relocating there will be a $25 address change fee.

 All renewals that are returned to the Board because of an incorrect address will be fined $25.

COMPLETING THE PAPER APPLICATION:

Paper applications are scanned. Please print legibly in ink, one character per box. All questions with an ‘*’ must be answered. Faxed

applications are not acceptable. If your information does not fit in the space provided, please include an 8 ½ x 11 paper with the

section # and information that needs to be updated.

CITIZENSHIP/LAWFUL PRESENCE DOCUMENTATION REQUIRED: Federal law 8 U.S.C. § 1641 and a state law A.R.S.

§ 1-501, placed into effect 1/1/2008, require documentation of citizenship/nationality/alien status for certification. If the

documentation does not demonstrate that the applicant is a United States citizen, national, or has alien status, the applicant will not be

eligible for certification in Arizona. All applicants must submit documentation regarding their citizenship/nationality/alien status once

after that 1/1/2008 date unless submitting a document with an expiration date (excluding US passports). If documentation has not yet

been submitted, see list A & B for specific documentation required. List A & B can be found at

by clicking

on Citizenship/Lawful Presence and Alien Status Declaration. A photocopy of the documentation you submit must be on 8 ½ x 11

paper.

FELONY CONVICTIONS: Pursuant to A.R.S. § 32-1646(B), the Board shall revoke a Nursing Assistant Certification if the applicant

for recertification has one or more felony convictions that have not previously been disclosed to the Board and the applicant has not

received an absolute discharge from the sentences for all felony convictions five or more years prior to the date of filing an application

for recertification. If you have been convicted of a felony since the date you were last recertified, your application will not be processed,

and proceedings for revocation of your nursing assistant certification shall be instituted by the Board.

REPORTING OF CRIMINAL CHARGES: Applicants for licensure/certification must notify the Board of criminal charges within 10

days of being charged. Further information is available at

NAME CHANGE: If you are submitting a name change (Question 2) include a copy of an official document showing previous

names (i.e. birth certificate, social security card, marriage license, diploma from high school) and a copy of an official document

showing your new name (i.e. marriage license, divorce decree, driver’s license, social security card).

TIME FRAMES FOR LICENSURE: The Board is required to process applications for licensure within certain time periods, per

Nurse Practice Act R4-19-102. Visit

and click on Rules for more information.

Please Note: If your application is not complete, the Board will send you a deficiency notice identifying any elements of the

application process which remain outstanding. For assistance with the application process for licensure, please contact Gail Maloney

at (602)771-7800. If you fail to respond to a deficiency notice within the applicable time period, your application will be withdrawn.

After withdrawal, if you are still interested in obtaining licensure you would need to submit a new application and applicable fee.

Cna Renewal Application Form

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