Nursing Assistant Registration Application

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Nursing Assistant Registration Application PacketContents:1. 667-025 ......Contents List/SSN Information/Mailing page2. 667-029 ...... Application Instructions Checklist ........................................ ........3 pages3. 667-001 ...... Nursing Assistant Registration Application .................................4 pages4. 667-038 ......Out-of-State Credential Verification Form .....................................1 page5. RCW/WAC and Online Website Links ........................................ ......................1 pageImportant Social Security Number Information:If you have a Social Security Number, the law requires you to disclose it on your Application for a professional or occupational license. 42 666(a)(13); RCW It will be used under the state s child support enforcement program to locate individuals for purposes of establishing paternity and establishing, modifying, and enforcing support obligations.

F Spouse or Registered Domestic Partner of Military Personnel Please print clearly. It is the responsibility of the applicant to submit all supporting documentation. Failure to do so may result in a delay in processing your application. Nursing Assistant Registered Application Nursing Assistant Registration Credentialing P.O. Box 1099

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