Registration

Name

Address

City

State

Zip

Phone Number

Email

School Name

School Phone

School Date

Course

Instructor

Date Graduated

Work Experience (if any)

How Long

Employer

I would like to register for the following exam
 Phlebotomy Technician EKG Technician Pharmacy Technician Medical Assistant Insurance Exam Tech Medical Laboratory Assistant Medical Billing & Coding Patient Care Technician Administrative Assistant Residential Care Worker Bridge Program CPR Personal Fitness Operating Room Surgical Instrument Sterile Processing Personal Care Assistant Ultrasound Diagnostic Medical Sonography Substance Abuse Intake IV Tech Healthcare Office Manager Homemaker Companion Assistant Healthcare Instructor Multi Skills Tech Physical Therapy Aide Emergency Room Tech Preparation Workshop

Exam Requirements

One must demonstrate eligibility in order to sit for an NHCWA national certification exam. You will be asked to show proof that you fulfill one of the following requirements in order to register for the NHCWA exam.

Complete at least ONE of the following:

• Graduation from an allied health vocational training program
• One year of work experience in the field
• Military experience/training in the field
• Reciprocity from another certifying agency

Cancellations

Refunds will not be offered for examination fees unless the scheduled examination date is cancelled by NHCWA. In the event you decide for any reason to withdraw from participation in the exam, you must cancel your appointment with NHCWA and notify NHCWA in writing with signature no later than 48 hours prior to the exam. If a candidate does not cancel or reschedule their exam with NHCWA at least 48 hours prior to the scheduled time, the cost of the exam is forfeited and the candidate must re-register as well as repurchase the exam. In the event that severe weather or another emergency forces the closure of a NHCWA test site on a scheduled examination date, the examination will be rescheduled by NHCWA at no additional charge. NHCWA personnel will attempt to contact candidates who are in this situation. However, candidates may also check the status of their examination schedules by calling NHCWA at 1-855-378-7601. Every effort will be made to reschedule the examination at a convenient time.

No-Show

If you fail to cancel for any reason fail to appear at the exam site where you are registered to sit for the exam you will forfeit all fees paid and no refund will be provided. You are considered a “no- show Candidate” and forfeit all fees. If you arrive late you may not be permitted to sit for the exam; whether or not you will be allowed to sit is entirely at the discretion of the NHCWA test center and will depend on whether the site has availability to accommodate a late-arriving Candidate. Should the late-arriving Candidate not be permitted to test, he/she will forfeit all fees paid and no refund will be provided. If you cancel or fail to appear for the exam you will be required to file a new application, pay applicable fees and meet applicable eligibility criteria if you wish to sit for future exams.

Rescheduling

Exam appointments can be rescheduled if time slots are available. To reschedule an exam appointment you must have your NHCWA confirmation number and you must reschedule by using the Reschedule option at www.nhcwa.com or by calling NHCWA at 1-855-378-7601.

One Time Credit Card Payment Authorization Form

Sign and complete this form to authorize National Healthcare Workers Association to make a one-time debit to your credit card listed below. **This transaction will read EDUCATION INC on your receipt. You can also call to register by phone 202-800-0227

By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

I authorize NHCWA to charge my credit card

account indicated below for on or after .

This payment is for:

I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card

company so long as the transaction corresponds to this authorization form.

(If the credit card you are using for this transaction is not in your name please

enter the name of the person the card belongs to below):

Did the owner of this card give you permission/authorization to use this card  yes no

I authorize the above named business to charge the credit card indicated in this authorization form according to

the terms outlined above. This payment authorization is for the goods/services described above, for the amount

indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card or

that I have been given permission to use this card by the owner of the card, and that I will not dispute the

payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

. **This transaction will read EDUCATION INC on your receipt

By providing your electronic signature below, you certify that you have read and understand the above information and that you meet the requirements listed above to sit for the NHCWA national Exam.

Electronic Signature (enter your name)