Fillable NURSE AIDE ONLINE TEST REGISTRATION (Iowa Western Community College)

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NURSE AIDE ONLINE TEST REGISTRATION (Iowa Western Community College)

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NURSE AIDE ONLINE TEST REGISTRATION
To register for the written (online) competency test, please co mplete this registration form. You must register in advance of the
testing. If you have questions, please call 712.325.3255. Form must be filled out completely.
Name:
SSN:
Birthdate:
Home Address:
City:
State:
Zip:
Phone (h):
Male Female
Facility where employed:
TRAINING HISTORY: (YOU MUST COMPLETE THIS PORTION OF FORM)
Instructor:
Last clinical date:
75 Hour Nurse Aide Course: Date: Location:
Previous Nurse Aide training other than 75 hour (60 hour, LPN, etc.):
No previous training.
TESTING HISTORY: Written (online) competency test taken time(s).
Provide Disability IEP paperwork and students have the option of having the written (online) exam read to them at no
additional charge. Please contact Iowa Western BEFORE scheduling a test date if you have questions .
ONLINE TEST
Date:
Time:
Online test fee: $55 - Testing fee due at time of registration.
Fee must be paid EACH time the test is taken.
TEST FEES ARE NONREFUNDABLE - Tests may be rescheduled
once
with 24 hour advance notice.
Money order, credit card or cash only - no personal checks accepted.
(Fill in ONLY if card is not available.)
Credit Card #:
Exp. Date:
3-Digit Code:
Name on Card:
Billing Address:
Payee Email:
Mail, fax or email completed form with your payment to:
Iowa Western Community College, Continuing Education
2700 College Road, Council Bluffs, IA 51503
Fax: 712-325-3721 l Email: swiese@iwcc.edu
Upon receipt of this registration form, IWCC will send you an admission slip with the date and time of your test. You must
show the admission slip and a photo ID to enter the testing area . NO ONE WILL BE ADMITTED WITHOUT THESE TWO
ITEMS.
My signature on this form indicates that I understand that:
I/my employer will be responsible for paying the testing fee if I do not show up for the test.
If I reschedule the test less than 24 hours before my test time, there is no refund for the original test and
I am
also responsible for the rescheduled test fee
.
I MUST have a photo ID to be allowed into the testing area.
Signature of Applicant:
Date:
PLEASE NOTE: THIS FORM FOR ONLINE TEST ONLY - SEPARATE FORM REQUIRED FOR SKILLS TEST
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NURSE AIDE ONLINE TEST REGISTRATION (Iowa Western Community College)

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Completed 29 January 2021

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