Transcription of CERTIFIED NURSE ASSISTANT AND/OR HOME HEALTH AIDE …
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CERTIFIED NURSE ASSISTANT AND/OR HOME HEALTH AIDE …
State of California HEALTH and Human Services AgencyCalifornia Department of Public HEALTH (CDPH) Licensing and Certification Program (L&C) Aide and Technician Certification Section (ATCS) MS 3301 Box 997416 Sacramento, CA 95899-7416 (916) 327-2445 FAX (916) 552-8785 NURSE ASSISTANT AND/OR home HEALTH AIDE RENEWAL APPLICATIONLast nameFirst nameMISexCheck here if you wish to have the name changed on your certificate. You must submit a legal document showing the name change. Mailing address (number and street name or Box number)CityStateZIP codeDate of birth*Social Security NumberTelephone number___ ___ ___ ___ ___ ___ ___ ___ ___TYPE OF REQUEST (Check all that apply. See additional information on back of this form.) Certificate number: _____Certificate number: _____I have successfully completed twenty-four (24) hours of in-service/continuing education (CE) hours during my most recent certification period (twelve (12) hours per year).
State of California—Health and Human Services Agency. California Department of Public Health (CDPH) Licensing and Certification Program (L&C) Aide and Technician Certification Section (ATCS)
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