Appendix A ‑ Form 6

State of Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road

Montgomery, Alabama 36106

1. (334) 271‑2342

   Request for Course Approval

   PLEASE MAKE SURE YOU ATTACH A BROCHURE FOR REVIEW

2. 1.  Submitted By:
3. 2.  Address:
4. 3.  Course Title:
5. 4.  Course Date & Location:
6. 5.  Course Objective and Content:  (A short paragraph describing the purpose of the course.)

7. 6.  Number of Hours requested

   (Only count actual classroom hours.  No credit can be given to the time spent in registration, coffee breaks, luncheons, dinners, or other nonformalized educational activities such as social hours.)

8. 7.  Sponsors of the Course:  Name

   Address

   Phone

9. 8.  Principle Faculty/Lectures/Speakers:

   ANY COURSE NOT RECEIVED IN THE BOE OFFICE AT LEAST 30 DAYS PRIOR TO THE DATE OF THE COURSE WILL NOT BE REVIEWED

Author: Jacob L. Cureton, Jr.

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

History: Amended: January 16, 2001; effective February 20, 2001.