Looking for a License Application Form Templates? Download it for free!

Application For Licensure - Medication Aide-Certified Institution/facility/association Page 3

State of Utah

& P

IVISION OF

CCUPATIONAL

ROFESSIONAL

ICENSING

160 East 300 South, P.O. Box 146741

Salt Lake City, Utah 84114-6741

Telephone (801) 530-6628

(Note: Microsoft Word users can fill in the blanks, print the form and save it for their records)

Medication Aide-Certified – Institution/Facility/Association

Please check one:

Educational Institution

A Health Care Facility

A Health Care Association

Name of /Institution/Facility/Association:

Physical Location:

City:

State:

ZIP:

Phone #:

FAX:

E-Mail:

Contact Person for Approval Purposes:

Title:

Name:

Mailing Address:

City:

State:

ZIP:

Contact Persons Direct Phone #:

FAX:

E-Mail:

DO NOT WRITE IN THIS SECTION - FOR DIVISION USE ONLY

Date Approved/Denied: ___/___/____ by

Reason for Denial/Other Comments:

____________________________________________________________________________________________________________

Bureau Manager Review:  Approve

 Deny

Date____________________

Comments:

DOPL-AP- Rev 2013-03-18

Application For Licensure - Medication Aide-Certified Institution/facility/association Page 3