CNA Registration Spring 2022 | Page 9

Required CNA Student Criminal History Statement

Check appropriate statements below , sign and date .
_____ At the time of enrolling in this program , I have been convicted of a crime . _____ At the time of enrolling in this program , I have criminal charges pending against me . _____ At the time of enrolling in this program , I have NOT been convicted of a crime .
_____ At the time of enrolling in this program , I do NOT have criminal charges pending against me .
If either of the first two lines have been checked , please provide a statement below explaining the crime or charges . You may make appropriate attachments .
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
All statements are subject to investigation . Statements of fact found to be false , exaggerated , or misleading , will result in your removal from the CNA program .
Signature ________________________________________________ Date ______________
Printed Name _______________________________________________________________
9 - of 16