1. (a) Requests for a nursing pool license shall be submitted on application forms made available by the Division. Each application shall include the following information:

   1. (1) Business identification consisting of the following:

      1. (A) The business name or names under which the licensed services will be offered in brochures, yellow pages, and other advertisements.
      2. (B) The full street address location of the office premises which the public will contact to obtain the offered nursing pool services.
      3. (C) The postal address of the office for which licensing is requested.
      4. (D) A listing or description of any state issued licenses applicable to the premises for which the application is submitted.

   2. (2) Ownership disclosure consisting of the following:

      1. (A) The name of the legal person, corporation, partnership, or proprietor, with ownership liability and authority applying for a license.
      2. (B) The name, business title, address, and telephone number of the proprietor, managing partner, or chief executive officer.
      3. (C) The name of other corporations, trusts, or holding companies involved when the applying entity is a wholly owned subsidiary corporation.
   3. (3) Names, title and telephone number of the on‑site manager for the location to be licensed.
   4. (4) General information on all health care related services expected to be offered to the public from the premises on the effective date of licensure.
2. (b) Nursing pools subject to this Subchapter, but exempt from separate licensure, shall submit an application in accordance with this Rule and an addendum to their existing license shall be issued.
3. (c) A copy of this Subchapter together with the governing statutes shall be maintained on the licensed premises for use by on‑site personnel.

History Note: Authority G.S. 131E‑154.4;
Eff. January 1, 1991;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 20, 2015.