Georgia - Nurse Aide Program

Nurse Aide Information
CNA Last Name :	Required	CNA First Name :	Required	Middle Initial :
CNA Address 1 :	Required	CNA Address 2 :
CNA City / State / Zip :	Required Required 5 digits is required	CNA County :	County
CNA Phone :	Phone 10 digits is required	State Transferring From :
CNA SSN #:	SSN 9 digits is required	CNA Date of Birth :	Date of Birth Invalid Range
Certification Number :	Required Please enter numeric values only	Certification Date :

Mailing Address :
Georgia Nurse Aide Registry
PO Box 105753
Atlanta, GA 30348

Verification of Employment

Are you currently working as a CNA?

Yes

Complete the employer information section below with your current CNA employer or if you are NOT currently working as a CNA, but worked within the prior 24 consecutive months as a nurse aide.

Acceptable Private Duty must be under the general supervision of a LPN/RN. Private Duty requirements must include a notarized statement with detailed job duties, signature of employer, signature of LPN/RN and license number, time frame worked and a copy of check stub or W-2 form as verification of employment.

N/A
Trained and/or passed the state competency examination within the last year.	Date Completed	Date Completed
No CNA employment history within the past two (2) years.

Check if unemployed

Most Recent Employer Information
Employer/Facility Name :	* Employer Name	Phone Number 1:	Phone
Employer Type :	Employer Type	Phone Number 2:
Address 1:	Address	Address 2:
City / State / Zip :	Required * State Required 5 digits is required	County :
Date Worked From :	* Date Worked From	Date Worked To :	* Date Worked To Still Employed

If there is a change of address, it is the sole responsibility of the CNA to report this change. The CNA has 10 working days to report the change so that the registry will be updated appropriately. Please allow 10 business days for processing and check the registry status on the web portal at www.mmis.georgia.gov.