CPE Compliance Orientation (DMS) Orientation Registration Form 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 Middle name Last Name Student ID number CNM E-Mail Address We only contact students via CNM email addresses. Please do not provide personal email addresses. Program Diagnostic Medical Sonography Registration Please indicate if you are registered or on the waitlist. Registered Waitlisted Orientation Date Please select the orientation date for your program. Zoom: Monday, August 12, 2024 - 1 p.m. - 2 p.m. Permanent/Physical Address Address Line City State 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. 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) Gender Choose OneMaleFemaleUnknown Eye Color Please select one of the options below Choose OneBlackBlueBrownGreyGreenHazelMaroonMulticoloredPinkUnknown Race Please selection one of the options below Choose OneAsianBlackNative AmericanWhiteUnknown Hair Color Please select one of the options below Choose OneBaldBlackBlondeBrownStrawberryGrey or Partially GreyRed or AuburnSandyWhiteOrangeUnknown Height Please list feet and inches Weight US Citizen Please indicate if you are a US Citizen YesNo Place of Birth Please include city and state Primary Phone Please include area code when entering phone number (XXX-XXX-XXXX) Primary Phone Type Choose OneHomeCellWork Aliases/Prior Names (Includes all names by which an applicant is currently known or has been identified as) Last, First, Middle Name Social Security and Date of Birth Prior Addresses within the last 7 years Year to & from (ex. 2012-2014) 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 Information Issuing State: Identification Information Issuing Authority Motor Vehicle DepartmentUnited States GovernmentUnited States Armed ForcesUnited States Department of Immigration Identification Information Document Number: (Drivers License# or Passport #) Identification Number Expiration Date (MM/DD/YYYY): Spam Check