Nursing Assistant Registration Application Packet
Contents:
1. 667-025 ......Contents List/SSN Information/Mailing Information.......................1 page
2. 667-029 ......Application Instructions Checklist ................................................3 pages
3. 667-001 ......Nursing Assistant Registration Application ................................. 4 pages
4. 667-038 ......Out-of-State Credential Verication Form .....................................1 page
5. RCW/WAC and Online Website Links ..............................................................1 page
Important Social Security Number Information:
If you have a Social Security Number, the law requires you to disclose it on your
application for a professional or occupational license. 42 U.S.C. § 666(a)(13); RCW
26.23.150. It will be used under the state’s child support enforcement program to locate
individuals for purposes of establishing paternity and establishing, modifying, and
enforcing support obligations. You are not required to have or obtain a Social Security
Number to apply for or obtain a license from the Department of Health. If you do not
have a Social Security Number, you are still eligible to apply for and obtain a credential
if you meet the requirements. Please see the Declaration of No Social Security Number
Form. Please call the Customer Service Center at 360-236-4700 if you have questions.
In order to process your request:
Mail your application with initial
documentation and your check Send other documents not
or money order payable to: sent with initial application to:
Department of Health Nursing Assistant Credentialing
P.O. Box 1099 P.O. Box 47877
Olympia, WA 98507-1099 Olympia, WA 98504-7877
Contact us:
360-236-4700
To request this document in another format, call 1-800-525-0127. Deaf or hard of
hearing customers, please call 711 (Washington Relay) or email civil.rights@doh.
wa.gov.
DOH 667-025 September 2021
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DOH 667-029 September 2021 Page 1 of 3
Important background check Information: Washington State law authorizes the
Department of Health to obtain ngerprint-based background checks for licensing
purposes. This check may be through the Washington State Patrol and the Federal
Bureau of Investigation (FBI). This may be required if you have lived in another state or
if you have a criminal record in Washington State. This would be at your own expense.
All information should be printed clearly in blue or black ink. It is your responsibility to
submit the required forms.
F Application Fee. This fee is non-refundable. You can check the online fee page for
current fees.
F Check if either apply:
Request for Military Training and Experience Evaluation
Spouse or Registered Domestic Partner of Military Personnel
F 1. Demographic Information:
Social Security Number: You must list your social security number on your
application. You are not required to have or obtain a Social Security Number
to apply for or obtain a license from the Department of Health. Please see the
Declaration of No Social Security Number Form. Please call the Customer Service
Center at 360-236-4700 if you do not have one.
National Provider Identier Number (NPI): The National Provider Identier (NPI)
is a standard unique identier for health care professionals available from the
Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric
identier. If you have a NPI number, provide this on your application.
Legal Name: List your full name: rst, middle, and last.
Denition of legal name: “Legal name” is the name appearing on your ocial
certicate of birth or, if your name has changed since birth, on an ocial marriage
certicate or an order by a court. The court must have the legal authority to change
your name. We may ask you to prove your legal name. If you use any name other
than your legal name on this form, your application may be denied.
Birth date: Provide the month, day, and year of your birth.
Address: List the address we should use to send any information about your
license. Be sure to include the city, state, zip code, county, and country. This will be
your permanent address with the Department of Health until we have been notied
of a change. See WAC 246-12-310.
Phone, Fax, and Cell Numbers: Enter your phone, fax, and cell numbers, if you
have them.
Email: Enter your email address, if you have one.
Other Name(s): Indicate whether you are known or have been known under any
other names. If you have a name change, you must notify the Department of Health
in writing. You must include proof of this change. See WAC 246-12-300.
Application Instructions Checklist
DOH 667-029 September 2021 Page 2 of 3
F 2. Personal Data Questions:
All applicants must answer the same personal data questions. They are focused on
your tness to practice the essential skills of this profession.
If you answer “yes” to any questions in this section, you must provide an
appropriate explanation. You must also provide the documentation listed in the note
after the question. If you do not provide this, your application is incomplete and it
will not be considered.
• Question 5 includes misdemeanors, gross misdemeanors and felonies. You do
not have to answer yes if you have been cited for trac infractions. You can get
copies of court records through the county courthouse where the conviction,
plea, deferred sentence, or suspended sentence was entered.
• If you have been granted certicate(s) of restoration of opportunity, please pro-
vide a certied copy of each certicate.
• Another jurisdiction means any other country, state, federal territory, or military
authority.
F 3. Other License, Certication, or Registration:
List all states, including Washington, where credentials are or were held.
Specically list credentials granted as temporary, reciprocity, exemption or similar
with type, date, grantor, and if credential is current. Attach additional completed
pages if you need more space.
F 4. Applicant’s Attestation:
You must sign and date this for us to process the application.
Other Information
Criminal history checks are conducted for all license applicants. If you answered
yes to any of the personal data questions, please submit the appropriate supporting
documentation as indicated on the application. If your application is incomplete, you will
be mailed a letter regarding the deciencies.
• The application is considered incomplete if requested information is left blank.
Write N/A or place a line through section instead of leaving blank.
• The initial registration will expire on your birthday unless the initial registration is
issued within 90 days of your next birthday.
• A courtesy renewal notice will be mailed to your address on record. You must
keep your address current with us. Any renewal postmarked or presented to the
department after midnight on the expiration date is late.
• Information regarding the Nursing Assistant program is available on our
website.
Note: You cannot practice as a nursing assistant until your registration is issued.
For Spouses and Registered Domestic Partners of Military
Personnel Being Transferred or Stationed in Washington:
Under state law, if you are the spouse or state-registered domestic partner of a
servicemember of any branch of the U.S. Military, to include Guard or Reserve, and
are applying for a health care professional credential in this state, you may be eligible
to have the processing of your application expedited to receive your credential more
quickly.
Documents to submit with your application should include the following:
• A copy of your spouse’s or registered domestic partner’s military transfer orders
to Washington State.
• One of the following:
- A copy of your marriage certicate to show proof of marriage; or
- A copy of a state’s declaration or registration showing you are in a state
registered domestic partnership with a member of the U.S. military.
For Current and Former Servicemembers Requesting
Evaluation of Military Training and Experience
Under state law, your military education, training, and experience may count towards
attaining certain civilian health care profession credentials in Washington State.
Submitted information will be reviewed by the Department of Health to determine
substantial equivalency for meeting the credentialing requirements in this state.
Documents to submit with your health care professional credential application should
include the following:
• If applicable, a copy of your DD214 Certicate of Release or Discharge from
Active Duty, Member-4 or service 2 copy, or NGB-22 for National Guard.
Please note:
- A copy of your DD214 can be downloaded from the EBenets website.
- You can request a replacement copy of your NGB-22 on the
National Archives website.
• Ocial Joint Service Transcript (JST) or Community College of the Air
Force(CCAF) Transcripts.
Please note:
- JST can be sent electronically by visiting the JST website and selecting
Washington State Department of Health.
- CCAF transcripts cannot be sent electronically. See the CCAF website for
transcript information.
• Verication of Military Experience and Training (VMET) or DD Form 2586. See
the DoDTAP website.
• If applicable, application for the Evaluation of Learning Experiences During
Military Service (DD Form 295). See the Military Resources website.
DOH 667-029 September 2021 Page 3 of 3
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DOH 667-001 September 2021 Page 1 of 4
Revenue 029903000
Date
Stamp
Here
Note: The mailing and email addresses you provide will be your addresses of record. It is your
responsibility to maintain current contact information with the department.
Name First Middle Last
1. Demographic Information
Country
Will documents be received in another name? F Yes F No
If yes, list name(s):
Address
City State Zip Code County
Have you ever been known under any other name(s)? F Yes F No
If yes, list name(s):
Country
Mailing address if dierent from above address of record
City State Zip Code County
Birth date (mm/dd/yyyy)
Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #)
Email address
F Male F Female
F Prefer not to answer
F X
Social Security Number (SSN)
(If you do not have a SSN, see instructions)
National Provider Identier Number (NPI)
(Enter 10 digit number)
Select if either apply: F Request for Military Training and Experience Evaluation
F Spouse or Registered Domestic Partner of Military Personnel
Please print clearly. It is the responsibility of the applicant to submit all supporting documentation. Failure to do so
may result in a delay in processing your application.
Nursing Assistant Registered Application
Nursing Assistant Registration Credentialing
P.O. Box 1099
Olympia, WA 98507-1099
1. Do you have a medical condition which in any way impairs or limits your ability to practice your
profession with reasonable skill and safety? If yes, please attach explanation. .......................................F F
“Medical Condition” includes physiological, mental or psychological conditions or
disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments,
cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes,
intellectual disabilities, emotional or mental illness, specic learning disabilities, HIV disease,
tuberculosis, drug addiction, and alcoholism.
If you answered yes to question 1, explain:
1a. How your treatment has reduced or eliminated the limitations caused by your medical condition.
1b. How your eld of practice, the setting or manner of practice has reduced or eliminated the
limitations caused by your medical condition.
Note: If you answered “yes” to question 1, the licensing authority will assess the nature,
severity, and the duration of the risks associated with the ongoing medical condition
and the ongoing treatment to determine whether your license should be restricted,
conditions imposed, or no license issued.
The licensing authority may require you to undergo one or more mental, physical or
psychological examination(s). This would be at your own expense. By submitting this
application, you give consent to such an examination(s). You also agree the
examination report(s) may be provided to the licensing authority. You waive all claims
based on condentiality or privileged communication. If you do not submit to a
required examination(s) or provide the report(s) to the licensing authority, your
application may be denied.
2. Do you currently use chemical substance(s) in any way which impair or limit your ability to
practice your profession with reasonable skill and safety? If yes, please explain. ...................................F F
“Currently” means within the past two years.
“Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally.
3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or
frotteurism? ............................................................................................................................................... F F
4. Are you currently engaged in the illegal use of controlled substances? ................................................... F F
“Currently” means within the past two years.
Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine)
not obtained legally or taken according to the directions of a licensed health care practitioner.
Note: If you answer “yes” to any of the remaining questions, provide an explanation and
certied copies of all judgments, decisions, orders, agreements and surrenders. The
department does criminal background checks on all applicants.
5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had
prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? ...F F
Note: If you answered “yes” to question 5, you must send certied copies of all court
documents related to your criminal history with your application. If you do not
provide the documents, your application is incomplete and will not be considered.
If you have been granted certicate(s) of restoration of opportunity, please
provide a certied copy of each certicate.
To protect the public, the department considers criminal history. A criminal history
may not automatically bar you from obtaining a credential. However, failure to report
criminal history may result in extra cost to you and the application may be delayed
or denied.
DOH 667-001 September 2021 Page 2 of 4
2. Personal Data Questions
Yes No
6. Have you ever been found in any civil, administrative or criminal proceeding to have:
a. Possessed, used, prescribed for use, or distributed controlled substances or legend
drugs in any way other than for legitimate or therapeutic purposes? ................................................... F F
b. Diverted controlled substances or legend drugs? ................................................................................F F
c. Violated any drug law? .........................................................................................................................F F
d. Prescribed controlled substances for yourself? ....................................................................................F F
7. Have you ever been found in any proceeding to have violated any state or federal law or rule
regulating the practice of a health care profession? If “yes”, please attach an explanation and
provide copies of all judgments, decisions, and agreements? . ...............................................................F F
8. Have you ever had any license, certicate, registration or other privilege to practice a health care
profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? ..............F F
9. Have you ever surrendered a credential like those listed in number 8, in connection with or to
avoid action by a state, federal, or foreign authority? ...............................................................................F F
10. Have you ever been named in any civil suit or suered any civil judgment for incompetence,
negligence, or malpractice in connection with the practice of a health care profession? .........................F F
11. Have you ever been disqualied from working with vulnerable persons by the Department of
Social and Health Services (DSHS)? .......................................................................................................F F
DOH 667-001 September 2021 Page 3 of 4
2. Personal Data Questions (cont.)
Yes No
3. Other License, Certication, or Registration
List all states, including Washington, where credentials are or were held. Specically list credentials granted as
temporary, reciprocity, exemption or similar with type, date, grantor, and if credential is current. Attach additional
completed pages if you need more space.
State/Jurisdiction
License Type
License
Number
Issue Date Expiration Date
License Method
Licensed
4. Applicant’s Attestation
I, ________________________________ , declare under penalty of perjury under the laws of the state of
Washington the following is true and correct:
• I am the person described and identied in this application.
• I have read RCW 18.130.170
and RCW 18.130.180 of the Uniform Disciplinary Act.
• I have answered all questions truthfully and completely.
• The documentation provided in support of my application is accurate to the best of my
knowledge.
• I have read all laws and rules related to my profession.
I understand the Department of Health may require more information before deciding on my application. The
department may independently check conviction records with state or federal databases.
I authorize the release of any les or records the department requires to process this application. This
includes information from all hospitals, educational or other organizations, my references, and past and present
employers and business and professional associates. It also includes information from federal, state, local or
foreign government agencies.
I understand I must inform the department of any past, current or future criminal charges or
convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability
to provide quality health care. If requested, I will authorize my health providers to release to the department
information on my health, including mental health and any substance abuse treatment.
Dated ________________ By: ______________________________________________________
(Original signature of applicant)(mm/dd/yyyy)
(Print applicant name clearly)
DOH 667-001 September 2021 Page 4 of 4
Part 2
To be completed by the state commission/board/committee and returned to the Washington State
Department of Health at the address provided above.
License/Certication/Registration issued on _________________ Number____________________________
Applicant licensed by: Exam _______________Endorsement ________________________________ Waiver
Status of License/Certication/Registration: F Current F Not Current If not, explain ________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Has license/certication/registration ever been encumbered in any way? (Revoked, suspended, surrendered,
restricted, placed on probationary status or under investigation.) F Yes F No If yes, explain ___________
_______________________________________________________________________________________
_______________________________________________________________________________________
Signature _______________________________________________
Name/Title_______________________________________________
State ___________________________________________________
Part 1: Note to applicant
Complete part 1 Submit form(s) to all state commissions/boards/committees where you have ever
been licensed, certied, or registered.
Name __________________________________________________________________________________
I was licensed/certied/registered by the ______________________________ Commission/Board/Committee
under the name __________________________________________________________________________
My original license/certication/registration number is ____________________________________________
My Address is ___________________________________________________________________________
Signature of applicant _____________________________________________________________________
Out-of-State Credential Verication Form
State
(SEAL)
Nursing Assistant Credentialing
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
DOH 667-038 September 2021
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DOH RCW/WAC and Online Website Link September 2021
RCW/WAC Links
Uniform Disciplinary Act, RCW 18.130
Administrative Procedure Act, RCW 34.05
Administrative Procedures and Requirements, WAC 246-12
Nursing Assistance Law, RCW 18.88
Nursing Assistance Rules, WAC 246-841
Online
Nursing Assistant Program, Web page
RCW/WAC and Online Website Links
