License Renewal Application Form (License #: Rca- )- State Of Idaho
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1Owyhee Plaza
STATE OF IDAHO
(208) 334-3233
1109 Main St., Suite 220
BUREAU OF OCCUPATIONAL LICENSES
Boise Idaho 83702-5642
LICENSE RENEWAL APPLICATION
License #: RCA-
Expiration Date: June 30 of each year
Renewal Fee: $75.00
The above noted renewal fee is for the next 12 month period and must be submitted to this office before the expiration date, also
noted above. License renewals submitted after the expiration date require a reinstatement fee of $25.00 in addition to the renewal
fee noted above.
Please submit this form with the required fee (check or money order) to the address noted above.
ALL RETURNED CHECKS ARE SUBJECT TO A $20.00 COLLECTION FEE.
PRINT NAME & ADDRESS BELOW AS IT
NOTE ADDRESS CHANGES BELOW:
APPEARS ON YOUR EXPIRING LICENSE
(Name changes must be accompanied by official
documents authorizing said change.)
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Please write your license number on your check or money order
DO NOT SEND CASH
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PERSONS LICENSED IN IDAHO FOR THE FIRST TIME DURING THE PREVIOUS 12 MONTHS OR HOLDING A CURRENT IDAHO
NURSING HOME ADMINISTRATOR LICENSE ARE CONSIDERED TO HAVE MET THE CONTINUING EDUCATION REQUIREMENTS FOR THIS
RENEWAL.
THE BOARD HAS DETERMINED THAT CONTINUING EDUCATION CREDIT WILL BE ALLOWED FOR COURSES MEETING THE
REQUIREMENTS OF RULE 401., AND WHICH CORRESPOND TO THE TOPICS LISTED UNDER RULE 300.04.
COURSES WHICH DO
NOT MEET THE REQUIREMENTS OF RULE 401. MUST BE INDIVIDUALLY APPROVED BY THE BOARD.
COURSE TITLE:
COURSE DATE(S):
SPONSORING ORGANIZATION & COURSE LOCATION:
TOTAL HOURS:
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TOTAL HOURS:
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CONTINUING EDUCATION CERTIFICATE OF COMPLIANCE
I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT I HAVE COMPLETED THE CONTINUING EDUCATION OUTLINED ABOVE AS
REQUIRED BY THE IDAHO RESIDENTIAL CARE FACILITY ADMINISTRATORS LAWS AND RULES.
I FURTHER CERTIFY THAT
DOCUMENTATION OF ALL OR PART OF THE CONTINUING EDUCATION OUTLINED BELOW MAY BE REQUESTED AND THAT FAILURE TO
SUBMIT REQUESTED DOCUMENTATION OR PROOF OF ATTENDANCE MAY RESULT IN ACTION AGAINST MY RIGHT TO LICENSURE.
SIGNATURE_________________________________________________
DATED THIS ____ DAY OF ________________, ______
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