Appendix A – Form 4

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama  36106

1. (334) 271‑2342

   Application for Renewal of NHA License

   (Please print clearly or type all answers ‑ if there is not sufficient space, use additional sheets and number accordingly).

   NHA License # ______________    E-mail address _________________    Date __________

   Last Four Digits Social Security # ___________

   In accordance with Act No. 986, Regular Session, 1969, I hereby make application for renewal of my license as a nursing home administrator with the Alabama Board of Examiners of Nursing Home Administrators.

   NAME:

   (Title)      (Last)                 (First)          (Middle)

   ADDRESS:  (Street)                                    (City)

   (State)                                  (Zip Code)

   Please give current home address

   NAME OF FACILITY OR BUSINESS:

   TELEPHONE:   (Cell)                              (Business)

   During the last year, have you been convicted of a felony or misdemeanor (other than minor traffic violation); entered a plea of guilty; entered a plea under a first offender provision; been a defendant in a malpractice claim or had a professional license or membership sanctioned either publicly or privately?

   No      O      Yes     O        If yes, attach copy of relevant documents.

   In addition to this license, I hold the following other professional licenses:

   License:                      ;                      ;

   (Title)                  (Number)                 (State)

   ;                      ;

   (Title)                  (Number)                 (State)

   Not Applicable      O

   Affidavit of Applicant

   I hereby certify that the                 (total hours) continuing education hours listed on this application are true and correct to the best of my knowledge and belief.

Author: Lana Davis, Chairman

Statutory Authority: Code of Ala. 1975, §34-20-13.

History: Amended: Filed January 16, 2001; effective February 20, 2001. Amended: Filed August 8, 2011; effective September 12, 2011. Amended: Filed March 13, 2012; effective April 17, 2012. Amended: Filed June 15, 2016; effective July 30, 2016. Amended: Published January 31, 2022; effective March 17, 2022.