Out-Of-State Nurse Aide Application To Become An Illinois Certified Nurse Aide (Cna) - Illinois Department Of Public Health

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State of Illinois
Illinois Department of Public Health
Out-of-State Nurse Aide Application to Become an Illinois Certified Nurse Aide (CNA)
Southern Illinois University Nurse Aide Testing
1840 Innovation Drive, Suite 103, Carbondale, IL 62903
Phone: 877-262-9259 Fax: 618-453-4300 Email: wednat@siu.edu
All information requested on this application must be provided before you will be evaluated.
(Please type or print legibly)
Today’s Date
Name
(First, Full Middle and Last)
Address
(Street, Apartment #, P. O. Box)
(City, State, ZIP Code)
Email
Telephone_________________________________
Social Security Number
State(s) where you have been certified as a CNA
Name used when certified
If your current name is different from the name you used when you were certified, please attach a copy of the legal document(s) used to
change your name (i.e. marriage certificate, divorce decree, etc.) and a copy of your driver’s license or other picture identification.
Maiden name or other names by which you have been known
Other states where you have lived or worked
I understand that the information requested regarding sex, race, height, eye color and date of birth is for the sole purpose of
identification and gathering the background check information. This information will not be used to discriminate against me in
violation of the law.
Male
Female Race
Height
Eye Color
Date of Birth
(Enter a letter from below)
A
Chinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander
B
Black or African American (Not Hispanic or Latino)
H
Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin)
I
American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states
of the United States or Alaska who maintains cultural identification through tribal affiliation or community recognition
U
Of undetermined race or of untold mixture
W
Caucasian (not Hispanic or Latino)
Have you ever had an administrative finding of abuse, neglect or theft?
Yes
No
If “yes,” indicate in what state this finding was issued

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