Michigan Nursing Assistant Registry Renewal Form at a glance
What it is: This is the Michigan Nursing Assistant Registry Renewal Form.
Where and when to file: Go to www.prometric.com/NurseAide/MI to print the current version of this application and all other forms. Do not submit photocopies as this may impact the ability to process the application. Incomplete, blurred or illegible forms will not be processed. Complete all of the information requested on this form, including the employer information on Page 2 of this form. Failure to fully complete all pages may result in delays or denial of the renewal of your certification. Mail completed original forms to Prometric, ATTN: MI Nurse Aide Registry Renewal, 7941 Corporate Drive, Nottingham, MD 21236.
What to bring and attach to Michigan Nursing Assistant Registry Renewal Form
If your legal name has changed since last communication with Prometric, you must provide a copy of acceptable legal documentation along with this application. Acceptable documents include marriage certificate; divorce decree; birth certificate; and legal name change court documents. Prometric will be unable to process your application until the legal acceptable documents are received.
A filled-in Michigan Nursing Assistant Registry Renewal Form example: a nursing assistant still working at her facility
How to fill out Michigan Nursing Assistant Registry Renewal Form, box by box
Nursing Assistant Information
All fields marked with * are required. Print one number/letter in each box where required.
Enter the Previous name (if applicable), the Street Address (including Apt. number or P.O. Box, if applicable), City, State, ZIP Code, County (first four letters only) and Daytime Phone Number (including area code). All fields marked with * are required.
The form will not be processed without an email address. All fields marked with * are required.
Employment Information
Under Employment Information, complete the following section with your current or previous employer information: Name of Employer, Address of Employer (Street Address or P.O. Box), City, State and Zip Code. All fields marked with * are required.
Enter the Date of Hire as MONTH/DAY/YEAR.
Mark Yes or No to Are you currently employed at the facility listed in Employment Information? If No, enter the Date of Termination as MONTH/DAY/YEAR.
Nursing Assistant Attestation and Signature
You certify that the information put forth on this Michigan Nursing Assistant Registry Renewal Form is true and correct to the best of your knowledge.
If you have given false information in this application, your nurse aide certification may be invalidated and you could be prosecuted by the state of Michigan.
Sign in the Signature of Nursing Assistant box and enter the Date.
Payment Form
On the Payment Form, enter the Candidate Name and the Date of Birth. All fields marked with * are required.
To pay by credit card, check one Credit Card Type (Check One): MasterCard, Visa or American Express, then enter the Card Number, Expiration Date, Amount, C/C Security Code, Name of Cardholder (Print) and Signature of Cardholder.
To pay by Certified Check or Money Order, check Certified Check, 3rd Party/Facility Check or Money Order and enter the check or money order number, one number or letter in each box.
Mail this completed form, any required documentation and the $20 non-refundable processing renewal fee in the form of a money order, certified check or American Express, Visa or Mastercard to Prometric Attn: Michigan Nurse Aide Registry Renewal, 7941 Corporate Drive, Nottingham, MD 21236 (checked November 9, 2026).
More rules for Michigan Nursing Assistant Registry Renewal Form
Fee(s) may be paid by money order or certified check made payable to Prometric. Your name and ID (if available) must be written on the form of payment. Personal checks and cash are not accepted. Fees are non-refundable and non-transferrable.
Make a copy of all completed forms for your personal records.
For additional information, please visit www.prometric.com/nurseaide.
Common questions about Michigan Nursing Assistant Registry Renewal Form
When is this form not the right one?
You are eligible to renew your certificate if you have worked as a nursing assistant performing nursing or nursing-related services to a patient or resident for pay for at least eight consecutive hours within the immediate 24-month period prior to your current registry document expiration date. Nursing assistants with employment restrictions on the registry for resident abuse, neglect, misappropriation of resident property or criminal record disqualifications are not eligible for renewal.
Sources
[1] Michigan Nursing Assistant Registry Renewal Form (Rev. 01292019), Prometric (the Official source link on this page).
