Looking for a Application For Reinstatement? Download it for free!

Application Form For Reinstatement - Kansas Department For Aging And Disability Services Page 2

License in Another State

List all states in which you have ever held an adult care home administrator license since obtaining your Kansas

license:

State: ____________________

State: ___________________

State: ____________________

State: ___________________

State: ____________________

For each state, complete Part I of the Verification of License form, request that state’s board complete Part II and

return verification to the Kansas board.

Disciplinary Action - This information is required under Kansas law: KSA 65-3503(a)

Has any license, certification, or registration issued by Kansas or another state or entity been denied, refused for

renewal, suspended, revoked or subjected to any other disciplinary action? Y / N

If YES, please explain:

________________________________________________________________________________________

__________________________________________________________________________________

Have you ever been convicted of a crime by any court (including Kansas), or any federal court of the United

States? Y / N . If YES, please indicate:

Date of conviction:____________________________________________________________________________

Crime of which convicted:_______________________________________________________________________

I do hereby attest that the information supplied in this application and any attachment is accurate and complete

to the best of my knowledge. I do hereby give permission to the board to verify any information provided in this

application and attachments. I understand that the application fee is non-refundable should I not meet licensure

qualifications.

Signature:_____________________________________________ Date:_____________________________

L L L L

PLEASE NOTE: YOUR SIGNATURE MUST BE NOTARIZED

SUBSCRIBED AND SWORN TO before me, the undersigned authority,

on this____________ day of_______________________, 20________

_________________________________________________________

(Notary Public)

My appointment expires:______________________________________

Submit application, fee and supporting documents to:

Health Occupations Credentialing

Kansas Department

Topeka KS 666

Application Form For Reinstatement - Kansas Department For Aging And Disability Services Page 2