NNAAP APPLICATION FOR NURSE AIDE CERTIFICATION BY ENDORSEMENT
[Pages:1]District of Columbia
NNAAPTM
APPLICATION FOR NURSE AIDE CERTIFICATION BY ENDORSEMENT
1. Mail this application and a $15 money order made payable to Pearson VUE, along with copies of your social secu
rity card, your current out-of-state nurse aide certificate/license, and signature-bearing photo identification, to:
Pearson VUE
DC Nurse Aide Endorsement
PO Box 13785
Philadelphia, PA 19101-3785
2. PERSONAL INFORMATION
LAST NAME
FIRST NAME
MI
MAIDEN NAME
--
DATE OF BIRTH
--
--
SOCIAL SECURITY NUMBER
MONTH DAY
YEAR
DAYTIME PHONE NUMBER
2a. NAME AS IT APPEARS ON YOUR ORIGINAL CERTIFICATE, if different than above
LAST NAME
FIRST NAME
MI
3. CURRENT MAILING ADDRESS
STREET
CITY
STATE
ZIP CODE
4. CONVICTION INFORMATION
Have you ever been convicted of, pled guilty to, or pled no contest to a violation of any federal, state, or other law constituting
a felony or misdemeanor, including convictions for driving under the influence (DWI) but excluding traffic violations? YES NO If "YES", explain in detail on the back of this form and include a copy of the court order.
Have you ever had any action taken against you or been denied a license or certificate in a health-related field? YES NO If "YES", explain in detail on the back of this form.
5. EDUCATIONAL INFORMATION
NAME OF NURSE AIDE EDUCATION PROGRAM
STREET
CITY
STATE
ZIP CODE
-- DATE OF COMPLETION
MONTH DAY
YEAR
6. EXAMINATION INFORMATION
EXAMINATION TAKEN: NACEP
Pearson VUE
ETS
-- EXAMINATION
COMPLETION DATE:
MONTH DAY
YEAR
NOTE: The District of Columbia only recognizes the Nurse Aide Competency Evaluation Program (NACEP),
Pearson VUE, and Educational Testing Services (ETS) certification examinations.
7. PERMISSION FOR RELEASE OF INFORMATION
I hereby give my permission to the appropriate certifying agency or registry in the state of __________ to
release information to Peason VUE for the purpose of certificate verification.
State in which you are currently certified
Signature of Applicant
Date ?2008 Pearson Education, Inc., or its affiliates. All Rights Reserved.
Stock# 0709-09 8/04 rev 3/08
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