COMFORT PARADISE TRAINING INSTITUTE CERTIFIED NURSE ASSISTANT (CNA) APPLICATION

Comfort Paradise Training Institute Los Angeles
State of California- Health and Human Services Agency
CERTIFIED NURSE ASSISTANT (CNA) INITIAL APPLICATION
TYPE OF REQUEST
(complete sections I, II, III and V)

Check here if you are enrolling in a CNA training program (complete sections I, II, III, IV, and V)Check here if you are requesting RECONSIDERATION for a previously revoked/denied certificate
SECTION II (REQUIRED)
Name*

First NameLast Name
MI
Sex

MaleFemale
Public Address (Required) – Subject to Public Records Act Request release**
Address*

Confidential Address Required- For CDPH Use only. If left City

Street Address Line 2

CityState

Zip Code
Confidential Address (Required)- (For CDPH Use only. If left blank all departmental mail will be sent to the address above)
Address

City

Street Address Line 2

CityZip Code

Postal / Zip Code
State
Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN)**If you use an invalid SSN, your application process*
Driver’s License /State ID Number*
State: *
Date of Birth(mm/dd/yy)*
Phone Number*
Email Address*
example@example.com
By checking this box, you agree to receive text messages from Comfort Paradise Training Institute (CPTI) for reminders and notifications regarding your application and/or certification. You may receive up to 5 messages per month.Message and data rates may apply. By checking this box, you agree to the Terms and Conditions and Privacy Policy.Reply “STOP” to opt-out, and “HELP” for help.
SECTION III (REQUIRED)
Have you been CONVICTED, at any time, of any crime, other than a minor traffic violation? (You need not disclose any marijuana-related offenses specified in the marijuana reform legislation and codified at the Health and Safety Code, Sections 11361.5 and 11361.7).*

Yes If yes, list conviction:No
If yes, list conviction:
Court of conviction
Date

MonthDayYear
Date
2)Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended, etc against you?
Type of License/Certificate:

YesNo
Type of License/Certificate
License/Certificate Number
Type of Action
SECTION IV (IF APPLICABLE)
Name of school or facility where you received/will receive the CNA training*
Address*

Mailing Address Number Street or P.O Box number

Street Address Line 2

CityState

Zip Code
Telephone Number
California Training Program ID Number for CNA (Required) CNA
Beginning Date of Training

MonthDayYear
Date
End Date of Training (mm/dd/yy)
SECTION V (REQUIRED)
I certify under penalty and perjury under the applicable state and federal laws that the information contained in this application and supporting documents, is true and correct. I further understand that any false, incomplete, or incorrect statements may result in denial of this application. I acknowledge that signing this document through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based record keeping system to the fullest extent permitted by applicable law.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
I certify that this individual has successfully completed state and federal nurseassistant training requirements and is eligible to take the Competency Evaluation(only applies to students that have recently completed a CNA Training Program in CA. Printed Name*
Date*
Signature*

Clear