Ala. Admin. Code r. 620-X-A-.03
Appendix A – Form 3
State of Alabama Board of Examiners of Nursing Home Administrators
4156 Carmichael Road
Montgomery, Alabama 36106
(334) 271‑2342
Application for License as a Nursing Home Administrator
Please print clearly or type all answers. If there is no sufficient space, use additional sheets and number accordingly. Your completed employment verification, copy of facility institutional license, photograph, organizational chart, three character references, a copy of your college degree, copy of current driver’s license, and the required fee (see fee schedule), made payable to the AL BOE of Nursing Home Administrators, must be submitted with this application. Your application will not be considered complete and therefore will not be reviewed unless all of the above have been received.
I hereby make application for a Regular License as a Nursing Home Administrator in the State of Alabama.
Date:
2. Home Address:
(Street) (City) (State) (Zip)
3. Business Address:
(Street) (City) (State) (Zip)
5. Date of Birth: Place of Birth:
(Month) (Day) (Year)
(c) Name of High School
Address:
(Street) (City) (State) (Zip)
(d) Name of College or University
Address
(h) Other educational training: Name
Address:
(Street) (City) (State) (Zip)
Dates attended: From To
Certificate Received: Yes ? No ?
Subjects:
9. Employment history for the past 15 years, include military experience, if any. Please list most recent experience first.
Employers Name
Address:
(Street) (City) (State) (Zip)
Employed: From To
List your title and a detailed description of duties performed, include number and type of employees supervised.
Employers Name
Address:
(Street) (City) (State) (Zip)
Employed: From To
List your title and a detailed description of duties performed, include number and type of employees supervised.
Employers Name
Address:
(Street) (City) (State) (Zip)
Employed: From To
List your title and a detailed description of duties performed, include number and type of employees supervised.
Employers Name
Address:
(Street) (City) (State) (Zip)
Employed: From To
List your title and a detailed description of duties performed, include number and type of employees supervised.
Employers Name
Address:
(Street) (City) (State) (Zip)
Employed: From To
List your title and a detailed description of duties performed, include number and type of employees supervised.
10. Membership in Professional Societies and Nursing Home Associations:
Name Date of Membership Offices Held Active or Inactive
11. Professional Certificates and/or licenses held. (Include such items as fellowships in American College of Hospital Administrators and American College of Health Care Administrators, MD, RN, LPN, CPA, etc. Do not include academic degrees. Give complete information for each certificate or license you hold or have ever held).
Type of certificate Name of State or Year of Original Year of Latest Current or Latest
or license other authority issue issue registration number
18. Have you ever had a certificate or other professional license revoked or suspended?
Yes ? No ? If yes, attach an explanation, relevant documents and a description of the current status.
19. Are you currently registered as a nursing home administrator in any other state?
Yes ? No ? If yes, please have the applicable State Licensure Board complete the enclosed reciprocity questionnaire. A questionnaire must be filled out for each state in which you hold or have held a nursing home administrators license.
(1) Name Business or Occupation
Address:
(Street) (City) (State) (Zip)
(2) Name Business or Occupation
Address:
(Street) (City) (State) (Zip)
(3) Name Business or Occupation
Address:
(Street) (City) (State) (Zip)
Affidavit of Applicant
, on oath, do promise and swear that, if my application is accepted, and I should be granted a license to practice as a Nursing Home Administrator in the State of Alabama, I will obey the laws of the State, the Rules and applications of the Alabama Board of Examiners of Nursing Home Administrators, and maintain the honor and dignity of the profession.
It is understood and agreed that, if I should fail to keep the above agreement or if I have made any false statements in this application, my license may be suspended or revoked by the Board at any time.
I further state that all the statements are made by me in this application are true and correct.
Signature of Applicant
Sworn to and subscribed before me this
day of , .
My Commission Expires
Notary Public
STATE OF )
COUNTY OF )
EMPLOYMENT VERIFICATION AFFIDAVIT
Before me, the undersigned Notary Public in and for said County, in said State,
personally appeared , who is known to me and
who, being duly sworn on oath deposes and says:
The affiant is of
(Title ‑ owner, co‑owner, officer, director, etc.)
and is personally acquainted with
(Nursing facility)
, who is an applicant for a license as a
nursing home administrator under the rules governing nursing home administrators
licensed under the laws of the State of Alabama, and that applicant has been
employed by the nursing facility from to .
(Date) (Date)
That applicant has good moral character and reputation where he/she resides,
and enjoys the confidence and respect of the general public. His/Her duties
are summarized as follows with dates indicated where appropriate to reflect
major duty changes or changes in responsibility:
Affiants Signature
Sworn to and subscribed before me
this day of , .
Notary Public My Commission Expires
County of
State of
Author: Linda U. Jordan, Chairman
Statutory Authority: Code of Ala. 1975, §34-20-5.
History: December 31, 1992. Filed: Amended: August 31, 1993. Amended: Filed January 16, 2001; effective February 20, 2001. Amended: Filed June 15, 2016; effective July 30, 2016.