State of California - Health and Human Services Agency
California Department of Public Health
Licensing and Certification Program
Aide and Technician Certification Section
MS 3301, P.O. Box 997416
Sacramento, CA 95899-7416
Phone: (916) 327-2445 Fax: (916) 552-8785
cna@cdph.ca.gov
REQUEST FOR NAME/ADDRESS CHANGE AND/OR
DUPLICATE FOR CNA/HHA/CHT CERTIFICATE
Please mail this form to the address above or fax to (916) 552-8785.
LAST NAME: FIRST NAME: MIDDLE NAME:
CERTIFICATE NUMBER:
DATE OF BIRTH:
(Month/Day/Year)
*SOCIAL SECURITY NUMBER:
PHONE NUMBER:
CURRENT ADDRESS: (Number and Street)
City State Country (if other than U.S.) Postal/ZIP Code
PREVIOUS ADDRESS: (Number and Street)
City State Country (if other than U.S.) Postal/ZIP Code
Section III
SUBMIT A PHOTOCOPY OF THE LEGAL DOCUMENTATION WITH THIS FORM FOR NAME CHANGES. (This
document must show your current and previous name.) Examples of acceptable forms of legal documentation are
marriage certificate, divorce decree or court documents.
PREVIOUS NAME: Last
First Middle
NEW NAME: Last
First Middle
Section IV
To request a replacement certificate, check the boxes below to indicate the replacement certificate type you are
requesting:
*Social Security Number Disclosure: Pursuant to Section 666(a)(13) of Title 42 of the United States Code and California Family Code section 17520. subdivision (d), the California Department of Public
Health (CDPH) is required to collect Social Security numbers (SSNs) from all applicants for nursing assistant, home health aide, hemodialysis technician certificates or nursing home administrator
licenses. Disclosure of your SSN is mandatory for purposes of establishing, modifying, or enforcing child support orders upon request by the Department of Child Support Services and for reporting
disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR subsection 61.1 et seq. Failure to provide your SSN will result in the return of your application. Your SSN will
be used by CDPH for internal identification, and may be used to verify information on your application, to verify certification with another state's certification authority, for exam identification, for
identification purposes in national disciplinary data bases or as the basis of a disciplinary action against you.
CDPH 0929 (07/11) This form is available on our website at: www.cdph.ca.gov
CNA HHA CHT
Section I
Address Change Name Change Duplicate Request
PLEASE PRINT OR TYPE
Section II
REQUEST TYPE: (Check all that apply)
(Must complete Sections I, III & V)
(Must complete Sections I, II & V)
(Must complete Sections I, IV & V)
Reason for request:
Signature
Date
Section V
