Personal Information

Name

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Why do you want to become a Certified Nursing Assistant?

Yes

EDUCATION BACKGROUND

Highest Level of Education Completed

Some High School-currently enrolled

Some High School-not currently enrolled

High School Graduate or GED

College-currently enrolled

College-not currently enrolled

Name of Last School Attended:

Year Graduated/Will Graduate or Last Attended:

Do you have any previous healthcare experience?

Yes

If yes, please describe your experience. Otherwise, mark NA.

EMPLOYMENT HISTORY

Current Employer (if applicable):

Role/Position

Employment Dates

May we contact your current employer?

Yes

REFERENCES

Reference #1 (Name, Relationship, Phone Number):

Reference #2 (Name, Relationship, Phone Number):

Reference #3 (Name, Relationship, Phone Number):

North Valley Hospital District's Equal Employment Opportunity Statement

At North Valley Hospital District, we firmly uphold the principle of equal employment opportunity for all individuals. We are committed to creating a diverse and inclusive environment free from discrimination and harassment. We ensure equal employment opportunity for all applicants without regard to race, color, religion, sexual orientation, sex, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, military status, or status as a covered veteran or other legally protected characteristics. We will consider all qualified applicants with criminal histories for employment in a manner consistent with applicable law. At North Valley Hospital District, we continually strive to build a team that reflects the rich diversity of our community and the communities we serve. We believe that a diverse workforce and inclusive workplace culture enhance the performance of our organization and are essential in our drive toward achieving health equity for all.

Agreement and Signature

By clicking SUBMIT, I certify that the information in this application is accurate and complete to the best of my knowledge. I understand that any false information or omission may disqualify me from further consideration for the CNA course and may result in my dismissal if discovered later.

NAC Class Application

nac class interviews BEGINNING in january 2025

class start date to be determined

accepting applications through january 6th 2025

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(509)486-2151 | nvhospital.org

203 S. Western Avenue, Tonasket, WA 98855