Submit New Application


NOTE: Please do not use this system for renewing your nurse aide certification in Wisconsin. For assistance with renewal, contact the Wisconsin Department of Health Services at

DO NOT COMPLETE THIS FORM if you have ever been listed on the Wisconsin Nurse Aide Registry. Check for your certification status on the Wisconsin NA Registry at

Please read these directions before you complete and submit this form. Your request for reciprocity cannot be processed if it is incomplete, illegible, or includes false statements.

TRAINING: You must have completed a (minimum) 75-hour state-approved nurse aide training program (with the date of completion noted) to be considered for the Wisconsin Nurse Aide Registry. State registry printouts and certificates that do not provide training program names or dates of completion are not acceptable. [Wis. Admin. Code DHS 129.09(5)(b); Wis.Stat. § 146.40(2)(d); (2g)(a),(b)]

Acceptable proof of training includes:
  •  A copy of your diploma or transcripts from your training program (with date of completion), 
  • Or a letter from the training program stating where and when you completed the training 
If you are unable to provide proof of training, you may instead include proof of qualifying employment:
Your employer(s) must verify you worked as a nurse aide under the direction of a registered nurse (RN) or licensed practical nurse (LPN) for at least 2,088 hours in the two years preceding your application to the Wisconsin Nurse Aide Registry. Please use the employer verification form 9110WI-A. Click here for the 9110WI-AIf you worked in multiple facilities/locations, you may complete more than one employment verification form 9110WI-A. Please upload all employment verification forms (9110WI-A) with this application.

ALABAMA APPLICANTS: If you originally trained in Alabama more than two years ago and are only certified in Alabama, you must also include employment verification that you worked as a nurse aide under the direction of an RN/LPN during the previous two years. Please use the employer verification form 9110WI-A. Click here for the 9110WI-A form.

Complete this form, 9110WI. Attach required training and identification documents. Pay the non-refundable reciprocity verification and processing administrative assessment fee of $25 through the secure credit card processing portal. Please note: Completing this form requires the following attachments: 
  1. Proof of Training and/or Employment Verification (using Form 9110WI-A) 
  2. Image of your social security card 
  3. Image of your valid US government-issued photo identification (state driver’s license, passport, or other signed current, photo identification). 
Your application is not complete until the required information is included, then select “Send Application.”
Reciprocity Information
Required Question
  • I have uploaded my current US government-issued, signed photo ID.
  • I have uploaded my social security card.
  • I have uploaded either proof of training completion or completed the (click link) Employer Verification Form(s) 9110WI-A
  • If I am an Alabama Reciprocity applicant, I have completed and uploaded the (click link) Employer Verification Form(s) 9110WI-A.
    • *NOTE: If you have an iCloud email, you may not receive our communications and you may need to call to check your status.
I agree that if all the requested documentation is not submitted with this application, and I do not reply to any of D&SDT-Headmaster's *emailed requests within one (1) month of submitting my application, my application will be denied and I will need to resubmit a new application and repay the fee.

I agree that my application will be denied if D&SDT-Headmaster:
  • Is unable to verify my registry status on another state's nurse aide registry.
  • If I have listed an offense on my application.  (Please contact for more information.)
By Submitting
I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.
Application Fee $25.00
Non-Refundable. All fees are non-refundable.