Appendix A – Form 9

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama  36106

1. (334) 271‑2342

   Application for Facility Training Site

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

   NAME OF FACILITY:

   ADDRESS:   (Street)                                     (City)

   (State)                                       (Zip Code)

   TELEPHONE:                                          (Fax)

   NUMBER OF LICENSED BEDS:                            COUNTY:

   OWNER:

   Please provide the following information on the facility key staff and department heads:

   NAME              POSITION IN FACILITY  DATE HIRED  WORK HOURS  TYPE OF LICENSE HELD LICENSE #

   PLEASE ATTACH THE LATEST COPY OF YOUR SURVEY REPORT (HCFA 2567) WHICH INCLUDES YOUR PLAN OF CORRECTION AND A COPY OF YOUR FACILITY LICENSE ISSUED FROM THE DIVISION OF LICENSURE AND CERTIFICATION.

Author: Jacob L. Cureton, Jr.

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

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