Get Initial Application

Filling out the Initial Application is a crucial step towards becoming a certified hemodialysis technician in California. This guide provides clear and detailed instructions to assist users in completing the form accurately and efficiently.

Follow the steps to successfully complete your Initial Application online.

1. Press the ‘Get Form’ button to access the Initial Application and open it in your preferred editor.
2. Provide your personal details in the relevant fields, including your last name, first name, middle initial, and sex. Ensure that all information is entered accurately.
3. Fill in your address details, including number and street or P.O. Box, city, state, and zip code. Make sure that the information matches your current residency.
4. Enter your date of birth and Social Security Number (SSN) as required. Remember that providing your SSN is mandatory and helps in identification.
5. Indicate your driver's license number if applicable, ensuring the number is correctly transcribed.
6. Answer the health-related licensing question regarding any adverse actions taken against you in the past, and provide details if necessary.
7. Proceed to the education section, stating whether you possess a high school diploma or equivalency. If applicable, include the name and address of the educational institution as well as the date of attainment.
8. In the training section, provide the details of the CHT training program you completed, including the name, provider number, address, and the RN trainer’s printed name and signature.
9. For the test/examination section, list the name and address of the provider where the examination was passed and include the proctor's printed name and signature, along with the pass date.
10. Conclude by certifying the accuracy of the provided information by signing the application and dating it. Review all entries to ensure completeness and correctness.
11. Once you have filled out the form, save your changes. You may choose to download, print, or share the completed Initial Application as required.

Ready to take the next step? Complete your Initial Application online now!