State of California - Health and Human Services Agency California Department of Public Health Nursin 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the 'NAME OF ADMINISTRATOR' field. Ensure that this matches your official documentation.
3. Input your NHA LICENSE NO. in the designated field to verify your credentials.
4. Provide your telephone number, ensuring you include the area code in parentheses.
5. Fill in your email address for any correspondence regarding your application.
6. Complete the 'ADDRESS OF RECORD' section with your street address, city, state, and zip code.
7. List each course completion date and corresponding course approval number as required.
8. Enter the title of each course completed along with the total course hours for accurate record keeping.
9. Remember to upload copies of certificates of completion alongside this form before submission.
10. Finally, sign and date the form to confirm that all information provided is accurate and true.

Start using our platform today for free to streamline your document editing and submission process!