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Collects applicant personal information including name, birth date, addresses and phone numbers, with Equal Opportunity data for statistical reporting. Includes email notification consent and a public records disclosure notice for email addresses. Requires Social Security disclosure details with federal and Florida statutory references, then gathers applicant background: prior names, education and licensing names, prior CNA applications in Florida, prior CNA licenses, other health-related licenses, and out-of-state verification requirements. 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Box 6330  \nTallahassee, FL 32314-6330  \nFax: 850-617-6460  \n[Email: MQA.CNA@flhealth.gov](Email: MQA.CNA@flhealth.gov)  \nRequests to withdraw must be made in writing. The request must be received prior to the board considering licensure.  \n1. PERSONAL INFORMATION  \nName:   Date of Birth:    \nLast/Surname First Middle MM/DD/YYYY  \n\n| Street/P.O. Box Apt. No. City |  |\n| --- | --- |\n| State ZIP Country Home/Cell Telephone (Input without dashes)\u003Cbr>Physical Location: (Required if mailing address is a P.O. Box-This address will be posted on the Department of Health’s website. ) |  |\n| Street | Apt. No. City |\n\nState ZIP Country Work/Cell Telephone (Input without dashes)  \nEQUAL OPPORTUNITY DATA:  \nWe are required to ask that you furnish the following information as part of your voluntary compliance with 41 CFR Part 60-3-Uniform Guidelines on Employee Selection Procedure (1978); 43 FR 38295 and 38296 (August 25, 1978) . This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure.  \nGender: Male Race: Native Hawaiian or Pacific Islander Hispanic or Latino White  \nFemale American Indian or Alaska Native Black or African American Asian  \nTwo or More Races  \nEmail Notification: To be notified of the status of your application by email check the “Yes”box and fill in your email address on the line provided. If you choose to be notified via email you will be responsible for checking your email regularly and updating your email address with the board office.  \nYes No Email Address:    \nUnder Florida law, email addresses are public records. If you do not want your email address released in response to a public records request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing.  \nDH‐MQA 5022, Revised 6/2020, Rule 64B9‐15 .0035, F.A.C. Page 2 of 14  \n2. SOCIAL SECURITY DISCLOSURE  \nThis information is exempt from public records disclosure.  \nPursuant to Title 42 United States Code § 666(a)(13), the department is required and authorized to collect Social Security Numbers relating to applications for professional licensure. Additionally, section (s. ) 456 .013(1)(a), Florida Statutes (F.S. ), authorizes the collection of Social Security numbers as part of the general licensing provisions.  \nLast Name:    \nFirst Name:  \n_____________________________________________________________  \nMiddle Name:    \nSocial Security Number:    \n(Input without dashes)  \nSocial Security Information- * Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, § 653 and 654; and s. 456.013(1), 409.2577, and 409.2598, F.S. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to ensure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for license identification pursuant to Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act. 104 Pub. L. Section 317) . Clarification of the SSA process may be reviewed at [www.ssa.gov](www.ssa.gov) or by calling 1-800-772-1213.  \nDH‐MQA 5022, Revised 6/2020, Rule 64B9‐15 .0035, F.A.C. Page 3 of 14  \nName:    \n3. APPLICANT BACKGROUND  \nA. List any other name(s) by which you have been known in the past. Attach additional sheets if necessary.  \nB. What name(s) did you use when you received your education?    \n______________________________________________________________________________________  \nC. What name did you use when you were first licensed?    \nD. Have you ever applied for Certified Nursing Assistant (CNA) lice","cbCaiqe412eiCXAR","https://ap.wps.com/l/cbCaiqe412eiCXAR","pdf",2920648,"English","# Personal Information\n## Equal Opportunity Data\n## Email Notification and Public Records Notice\n# Social Security Disclosure\n# Applicant Background\n## Prior Names and Licensing Names\n## Prior CNA Applications in Florida\n## Prior CNA Licenses\n## Other Health-Related Licenses and Out-of-State Verification\n# Disaster\n# Health History","[{\"question\":\"What personal information is required for the CNA endorsement application?\",\"answer\":\"The application requests the applicant’s name, date of birth, home and work contact details (addresses and phone numbers), and related required fields.\"},{\"question\":\"How does the form handle email and public records requirements?\",\"answer\":\"Email status updates are requested through a check box and email address line. The form states that, under Florida law, email addresses are public records, so applicants who do not want release must not provide an email address.\"},{\"question\":\"What disclosures are required for Social Security numbers?\",\"answer\":\"The form states the information is exempt from public records disclosure while citing federal and Florida statutory authority requiring Social Security numbers for licensure-related applications and efficient screening.\"}]","Certified Nursing Assistant Licensure by Endorsement Application | PDF",1789836984]