CPE Compliance Orientation (CVS) Orientation Registration Form for Cardiovascular Sonography Congratulations, you have successfully registered for a Coordinated Entry Program. Students who register in a Coordinated Entry Program will have to complete pre-clinical requirements. As a result, students must attend a mandatory compliance orientation. Please complete the form below in order to register for an orientation date. In order to prepare students for clinicals, the following information is required to complete the NM Department of Health Caregivers Criminal History Screening. All required fields are marked with a red box, indicating you must provide a response in order to successfully submit the form. NOTE: After you click submit, please print a copy of the Thanks page as proof that you submitted the form. You may be asked to provide this during your orientation. Students who do not attend this mandatory orientation may lose their spot in the program. First Name Last Name Aliases/ Prior Names (Includes all names by which an applicant is currently known or has been identified as) Student ID Number CNM E-Mail Address We only contact students via CNM email addresses. Please do not provide personal email addresses. Program Cardiovascular Sonography Registration Please indicate if you are registered or on a waitlist. Registered Waitlisted Orientation Date Please select the orientation date for your program. SV1-116: Thursday December 5, 2024 - 2 p.m. - 4:45 p.m. Permanent Physical Address Address Line City and State Example: Albuquerque, New Mexico Zip Code Mailing Address Please indicate Yes if mailing address is the same as Permanent Address Please indicate No if Mailing address is different than Permanent Address. You will have to provide your mailing address below Yes No Mailing Address If your mailing address is different from your physical address please type it in below. Prior addresses within the last 7 years Include the date range you lived in each address (Ex: 2005-2010) Primary Phone Number Please include your area code (xxx-xxx-xxxx) Primary Phone Type Choose one HomeCell Work Social Security or ITIN Number This is required in order to perform background check through New Mexico Department of Health (NMDOH). Please enter Social Security Number: (XXX-XX-XXXX) If you do not have a Social Security Number, please provide your ITIN number Date of Birth Please provide date of birth in the following format (MM/DD/YYYY) Place of Birth Please include city and state. U.S. Citizen Please indicate if you are a US citizen. yes no Gender Choose OneMaleFemaleUnknown Eye Color Choose OneBlack BlueBrown Green Hazel Multicolored Unknown Hair Color Height Please list your height in feet and inches. Weight Identification MUST UPLOAD A COPY OF THE DOCUMENT YOU ARE LISTING Identification Type Select document type Choose OneState Issued Driver’s LicenseState Issued Photo ID CardUS Armed Forces IDPassportVisa Identification Issuing State List the issuing state Identification Issuing Authority Please list the issuing authority. Motor Vehicle DepartmentUnited States GovernmentUnited States Armed ForcesUnited States Department of Immigration Identification Document Number Document Number (Drivers License Number or Passport Number) Identification Expiration Date Please use the following format: (MM/DD/YYYY) Spam Check