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TEST SITE Application

Please complete this application to be approved to administer the CNA knowledge exam at your location. In the Affidavit at the end of this document, you will attest that you have read, understood, and will abide by the following documents. Please print these documents and keep them for your records.

Click to Open: Test Site Agreement

Once you have completed all the fields in this application and uploaded the required images, select “Send Application" to submit it.

Name

Director of Nursing

Phone

Alt Phone

Administrator

Address

City

State

Zipcode

Mailing Address

Address

City

State

Zipcode

Additional Facility Information

Discipline Select the discipline type you are applying for.

Parent Facility Select the parent facility for this facility.

Candidate Directions to Test Site (if needed)

If needed, additional directions: Candidates receive a confirmation letter with the address of your facility upon scheduling. If you have any additional directions for how to get there or where to go once they arrive, please provide that information here. (For example, landmarks to look for, parking lot to use, building number, entrance number, floor and room number, or any other directions that help candidates get to your test site.

Affidavit

TEST SITE AGREEMENT:

I hereby agree to and understand that our testing location will administer the CNA Knowledge exam according to the guidelines in the Test Site Agreement.
I certify that our facility has not been prohibited from training or testing CNAs, under CMS regulations or other state sanctions.
I further attest that I have read, understood, and will abide by all listed guidelines in the Test Site Agreement.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.

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