| Date | Name | Date of Birth | Mobile Phone | Do you hold a current, active California LVN or RN license? | License Type | License Expiration | Eligibility Acknowledgment | Mailing Address | Preferred Schedule | Planned Start (Estimate) | Tell us briefly why you want this certification | Upload (optional): Government‑issued photo ID | Upload (optional): CPR/BLS Card | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Date | Name | Date of Birth | Mobile Phone | Do you hold a current, active California LVN or RN license? | License Type | License Expiration | Eligibility Acknowledgment | Mailing Address | Preferred Schedule | Planned Start (Estimate) | Tell us briefly why you want this certification | Upload (optional): Government‑issued photo ID | Upload (optional): CPR/BLS Card |
