CNA Application
Legal Name
*
First Name
Middle Name
*
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Personal Email Address - DO NOT use your school address. This must be a Permanent email address where you will receive information from the State of Illinois regarding your certification.
*
example@example.com
DACC Student ID Number
*
Birthdate
*
Social Security Number
*
What semester are you applying for
*
Fall
Spring
Either one
What is your preferred class location?
*
Danville
Hoopeston
Either one
Are you a high school student?
*
Yes
No
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Name of High School
Grade Level
12th grade
11th grade
10th grade
9th grade
Parent/Guardian Information
First Name
Last Name
Parent/Guardian Phone Number
-
Area Code
Phone Number
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Is English your first Language?
*
Yes
No
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Upload official document showing TOEFL Exam results
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Upload Proof of High School Completion or Enrollment
*
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Can be image of diploma or unofficial final high school transcript. If you are a current high school student, then upload a copy of your most recent report card showing Math and English grades.
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Upload image of your State Issued Photo ID
*
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IL Driver's license, IL state ID card or US Passport
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Proof of Social Security card
*
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By signing below, I verify and affirm that the information provided is true, correct, and complete to the best of my knowledge.
*
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