Appendix A – Form 8

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama  36106

1. (334) 271‑2342

   Application for Preceptor

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

   NHA License #                                  Date of Issuance

   NAME:

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

   DATE OF BIRTH:

   (Month)       (Day)      (Year)

   ADDRESS:   (Street)                                       (City)

   (State)                                         (Zip Code)

                             Please give current home address

   TELEPHONE:   (Home)                                (Business)

   Have you had any disciplinary action taken against any professional license you hold?  No ?  Yes  ?

   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   ?       Yes   ?      If yes, attach copy of relevant documents.

   In addition to this license, I hold the following other nursing home administrator licenses:       Not Applicable   ?

   License:                      ;                      ;                      ;

   (Title)                  (Number)                 (State)

   ;                      ;                      ;

   (Title)                  (Number)                 (State)

   Please list the names, addresses, and dates of the facilities in which you have been in direct management control over the last three years.  Please list current facilities first

   Please list your experience that would qualify you to supervise the training of an AIT.

   Education:  Please submit a copy of all degrees and certificates you have received.

2. (a)  Please circle the highest grade completed:  6   7   8   9   10   11   12
3. (b)  Did you graduate?   Yes  ?    No  ?  Date of Graduation

4. (c)  Name of High School

   Address:

   (Street)                     (City)                             (State)                      (Zip)

5. (d)  Name of College or University

   Address

6. (e)  Degree
7. (f)  Major undergraduate subjects:
8. (g)  Major graduate university subjects:

9. (h)  Other educational training:  Name

   Address:

   (Street)                     (City)                             (State)                      (Zip)

   Dates attended:  From                    To

   Certificate Received:  Yes  ?   No   ?

   Subjects:

   Please submit a copy of your current resume and a copy of your Preceptor Training Certificate.

   I hereby certify that the information listed on this application are true and correct to the best of my knowledge and belief.

   In witness whereof, I set my hand and seal this       day of             ,         .

   (Signature of Applicant)

   Sworn to and Subscribed before me this          day of                  ,          .

   (Notary Public)

   My Commission Expires             County of               State of

Author: Jacob L. Cureton, Jr.

Statutory Authority: Code of Ala. 1975, §34-20-9.

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