HCA State Exam Registration Form
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Please enter your DOB in MM-DD-YYYY format.
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Would You Like to Pay for Your State Exam?
*
Please Select
Self-Pay — Using Secure Payment Options Available on This Website
Long Term Care Foundation - LTCF
Which of the following do you currently have? (Select one)
*
I have my Pending License Number issued by the Washington State Department of Health
I do not have my Pending License Number yet, but I can provide proof that my application has been submitted (screenshot, PDF confirmation, printed confirmation, or other documentation required)
Upload a copy of your approved Washington State HCA 75-Hour Certificate
*
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