Nurse Aide Application - ND Health & Human Services

Registrant Information

Please complete the information below.

Contact Information

Please provide your current mailing address information below.


Mailing Address		Address Line 2
City	State	ZIP Code	County
Phone Number	Cell Phone Number	Email Address (If you don't have a personal email, list your work email address.)

Mailing Address Preference

All official Registry correspondence will be mailed to the address selected below.

I prefer to have mail from the Registry sent to my home address.

I prefer to have mail from the Registry sent to my business address.

Renewal Notification Preference

All renewal notifications will be sent to the preference selected below.

I prefer to receive renewal notifications from the Registry sent to my email address.

I prefer to receive renewal notifications from the Registry sent by text message to my cell phone number.

I prefer to receive renewal notifications from the Registry to be sent to both my email address and by text message to my cell phone number.