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)
SECTION II (REQUIRED)
Name

First NameLast Name
MI
Sex
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
Format: (000) 000-0000.
Email Address
example@example.com
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).
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:
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
Format: (000) 000-0000.
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
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

PAYMENT

Total

Payment Methods

Credit Card

Cash App Pay

Academic Session
Class
Section
Admission No
Enrollment Status
Should be Empty:

CERTIFIED NURSE ASSISTANT (CNA) INITIAL APPLICATION

TYPE OF REQUEST

SECTION II (REQUIRED)

SECTION III (REQUIRED)

SECTION IV (IF APPLICABLE)

SECTION V (REQUIRED)

PAYMENT

Payment Methods