Registration Form


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NameRegistration Form
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Registration Form
CNA School of Longview/Health Education Center

5612 Ocean Beach Hwy, Ste 110, Longview, WA 98632

360-747-7716 – cnalongview@gmail.com
Applicant Name:________________________________

Social Security Number _______-_____-________
Address:____________________________________________

City/State/Zip
Date of Birth (MM/DD/YYYY): ____________________________
Hispanic: __Yes __ No Race (Check one):

__ White/Caucasian

__ Black/African American

__ American Indian or Alaska Native

__ Asian

__ Hawaiian Native or other Pacific Islander

__ Multi-racial

__ Other

Disability: __ Yes __ No

Highest Grade Completed:


__ Less than high school graduation

__ High School Graduate Graduation Date ___________

__ GED Date GED Attained _____________

__ Some Post H.S., no degree or certificate __ Certificate (< 2 years)

__ Associate Degree (Year:______) __ Bachelor Degree or Above (Year:______)

Name and Address of Last School Attended____________________________________



  • I am aware that a Washington State Patrol Background check will be conducted on me by the CNA School of Longview and give my consent.


_____________________________________________________ _________________

Applicant Signature Date Signed

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