Gender: ___ Male ___ Female
Ethnicity/Race ___ White ___ Asian Indian
___ African American ___ Other Asian
___ Native American ___ Hispanic
___ Pacific Islander ___ Other
If you have tested for CNA with the Red Cross within last two years; indicate pass/fail information below. A copy of
your ARC score report must be submitted with this application from and the original ARC score report is required to
be submitted at the Test Site.
ARC Written Passed ___ Failed ___ Date of ARC Written Exam ______________
ARC Manual Skills Passed ___ Failed ___ Date of ARC Manual Skills Exam ______________
Please Note:
Registration forms and testing fees must be received in the office at least 10 business days or 14 calendar days prior
to the testing date (weekends and holidays do not count as business days). The regional Testing Center is not
responsible for late, missing or lost applications,
Please submit the following:
• Completed and signed Registration Application Form
• Cashier’s check or money order, payable to Regional Testing Center (cash or checks will not be accepted)
• COPY of your 283B form or your CA Department of Public Health approval letter (CDPH 932 form)
Incomplete registration applications or registration applications submitted with personal checks or cash will be
returned to sender, and the registration application will NOT be processed.
On the day of the exam you must bring:
• Original Social Security card (cannot be laminated)
• Current government issued photo identification
• Original 283B or original CDPH 932 approval letter
• Note: Failure to bring any of the above documents will prevent you from testing
By signing this form, I declare that the information I have provided is true and accurate to the best of my knowledge.
I understand that any false information or misrepresentation of facts may cause invalidation of my testing results.
I understand that my name must be exactly the same on the registration application, my social security card, my
government issued photo identification, and my CNA/HHA Initial Application (283B) or CDPH 932 approval letter. If
the names do not match on all three items I will not be allowed to take the CNA tests.
I authorize Pearson Vue, Inc. to release my evaluation results if requested by any agency that is authorized to
receive this information.
I also authorize Pearson Vue, Inc. to use my evaluation results for research purposes.
I have read and agree to the terms of this application.
Signed _________________________________________________ Date __________________
