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CNA Challenge Application

You must attach an image of one of the following when you complete this form:

An official copy of your transript with a letter on school letterhead from the program director verifying successful completion of the fundamentals of nursing and clinical rotation within the last 5 years.
A copy of out of country license or certificate, copy of school transcript translated to English and a copy of out of country criminal background check translated to English.
An official letter that states you completed the UAP or Patient Care Tech. This letter must be signed and dated from the Administrator or HR representative. This letter should also include the training hours completed through the UAP program.
A Certificate of Completion that also states UAP or PCT, and includes the training hours completed through the UAP program.
A copy of your Missouri Certificate or the Missouri CNA registry print-out.
Proof of your education and training in gerontology and health occupations.

Legal First Name

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Legal Last Name

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Item for Review of Challenge Request Application

Item for Review of Challenge Request Application You must attach an image of one of the following when you complete this form: - An official copy of your transript with a letter on school letterhead from the program director verifying successful completion of the fundamentals of nursing and clinical rotation within the last 5 years. - A copy of out of country license or certificate, copy of school transcript translated to English and a copy of out of country criminal backgroun check translated to English. - An official letter that states you completed the UAP or Patient Care Tech. This letter must be signed and dated from the Administrator or HR representative. This letter should also include the training hours completed through the UAP program. - A Certificate of Completion that also states UAP or PCT, and includes the training hours completed through the UAP program. - A copy of your Missouri Certificate or the Missouri CNA registry print-out. - Proof of your education and training in gerontology and health occupations.

SOCIAL SECURITY CARD

Please upload an image of your Social Security Card.

WHICH EXAM ARE YOU REQUESTING TO CHALLENGE?

Please complete: Please provide a written request that states you would like to challenge the CNA exam. Please be sure to include in your request an explanation of how you qualify to challenge the exam.

Affidavit

I have attached an image of one of the following items listed above for review of my request to challenge the exam in Missouri.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.

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