Telephone (208) 334-6620 Toll Free (800) 748-2480 Fax: (208) 334-6629
Return Completed & Signed Form To:
IDAHO NURSE AIDE REGISTRY
DIVISION OF LICENSING & CERTIFICATION – BUREAU OF FACILITY STANDARDS
IDAHO DEPARTMENT OF HEALTH & WELFARE
3232 ELDER STREET
P.O. BOX 83720
BOISE, ID 83720-0009
NURSE AIDE CERTIFICATION RENEWAL FORM
(PLEASE PRINT CLEARLY)
NAME: ______________________________ SOCIAL SECURITY #: ____________________
ADDRESS: ______________________________ DATE OF BIRTH: ________________________
CITY: ______________________________ EXPIRATION DATE: ___________________
STATE/ZIP: ______________________________ PHONE NUMBER: _______________________
(Your renewal will not be processed more than 45 days prior to your expiration date)
You must work at least 8 hours as a PAID CNA in the two years before your expiration date to be
eligible to renew for another 2 years.
You must sign below to authorize your employer to release employment information to the
Idaho Nurse Aide Registry.
Please note that volunteer hours do not count as hours toward renewing your certification.
There is NO fee required to renew your CNA certification.
Signature:________________________________________________________________________
Verification of CNA, HHA, or PCS Employment
Have your CURRENT or MOST RECENT NURSE AIDE EMPLOYER complete the section
below. If you are a PCS Provider, your CLIENT is your EMPLOYER and should provide the
following information.
Employer: _______________________________________ Phone Number: _________________
Street Address: __________________________________________________________________
City: ____________________________________ State: _______________ Zip: ______________
Employed FROM (mm/dd/yy) _______________ TO: (mm/dd/yy) _______________________
Employer’s Signature______________________________________________________________
