Cna Renewal Application Form (Page 9 of 14) in pdf

*12. APPLICATION QUESTIONS (must complete and sign before submitting)

i. Have you, since your certificate was granted or since your last renewal, whichever is later:

A. Been convicted, entered a plea of guilty, nolo contendere or no contest, been sentenced or served time in jail for any felony or

undesignated offense?

B. Had prosecution deferred or probation deferred in any felony or undesignated offense?

C. Had a felony or undesignated offense pardoned, expunged, dismissed, deferred, reclassified or redesignated?



Yes

If yes, provide:



A detailed written explanation of the details of each arrest conviction and sentence.



Copy of the police report.



Copy of court documents for each arrest conviction indicating type of conviction, conviction date,

and sentence.



Documentation showing absolute discharge, including the date of absolute discharge of the sentence

for each felony or undesignated offense conviction.



If yes, has this previously been reported to the Arizona Board of Nursing?

Yes

ii. Since your last renewal, have you had any drug or alcohol related convictions?



Yes

If yes, provide a detailed written explanation of the details of each arrest conviction and sentence. Return the

written explanation and court documents for each conviction indicating type of conviction, conviction date,

and sentence.



If yes, has this previously been reported to the Arizona Board of Nursing?

Yes

iii. Since your last renewal, has disciplinary action or revocation been taken or is there currently a complaint, investigation, or disciplinary action

pending against your CNA certificate or, any other health care or non health care related license or certification, in any state or territory of the

United States? (If your nursing license/CNA certificate is under investigation in Arizona only, do not mark yes.)



Yes

If yes, include a detailed written explanation and a copy of the documentation regarding the current

investigation or pending disciplinary action with your application.



If yes, has this previously been reported to the Arizona Board of Nursing?

Yes

PLEASE BE ADVISED THAT FAILURE TO PROVIDE THE REQUESTED DOCUMENTS WILL DELAY THE PROCESSING OF YOUR

APPLICATION

*VERIFICATION BY OATH OR AFFIRMATION OR DECLARATION

The undersigned declares under penalty of perjury under the laws of Arizona, that he/she:



Is the person referred to in the foregoing application;



That the statements are true in every respect to the best of his/her knowledge;



That he/she has not suppressed any information that would affect this application;



That he/she will conform to ethical standards of conduct in the profession of nursing and obey the laws and rules of the Arizona Board of

Nursing;



That he/she has read and understands that failure to disclose the requested information or disclosure of false information or disclosure of

misleading information may constitute fraud and may result in denial of licensure/certification or disciplinary action, up to and including

revocation, taken against an issued license or certificate



Failure to disclose the requested information or disclosure of false or misleading information may also result in criminal prosecution.

REMEMBER TO ENCLOSE A COPY OF CITIZENSHIP OR ALIEN STATUS DOCUMENTATION ON 8 ½ BY 11 PAPER WITH THE APPLICATION

IF NOT PREVIOUSLY SUBMITTED.

________________________________________________________________________

___________________________________

Applicant’s Signature

Date

PLEASE NOTE:

Online Renewal- If renewing online and proof of citizenship/lawful presence documentation has already been received and processed by the

Board, your license will be immediately renewed and verifiable via the license verification on our website ( ) within minutes. You

can renew online 24 hours a day, 7 days a week.

Paper Renewal- It may take up to 2 weeks to process your application. Do not send more than one application as it will not expedite your

renewal. Your employer may not be able to verify your renewal if you do not submit the application 2-3 weeks before the expiration date. If this

application is not postmarked by midnight of your expiration date and you have been working on your certificate you will be required to pay an

extra fee for late renewal. If your application is not completely filled out or if the fee is incorrect, it will be returned to you and further delay the

renewal process.

Please staple all pages of the application together with

documentation of citizenship or alien status and

ARIZONA STATE BOARD OF NURSING

mail to:

4747 N. 7

STREET, SUITE 200

PHOENIX, AZ 85014-3655

CNRF