Issuing Of Duplicate License-Duplicate Administrator License Request Form Page 2
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1
2Duplicate Administrator License Request
The duplicate will be issued to a single specific location under the administrator’s name and license
number and is valid as long as you are appointed as the administrator of record at that location, but
for no longer than 90 days. This request will also serve as your Notice of Appointment pursuant to
AAC R4-33-211. You must also have a valid fingerprint clearance card pursuant to AAC R4-33-
109.
Complete and return this form with a $75.00 money order or certified check payable to the “NCIA
Board” at 1400 W. Washington, Suite B-8, Phoenix, AZ 85007
Administrator Information
Administrator Name:
License #:
Address
City
St.:
Zip:
Telephone:
Fax:
E-mail:
Start date duplicate will be posted at below listed nursing care institution:
Nursing Care Institution where duplicate will be posted.
Institution Name:
DHS #
Address:
City
St.:
Zip:
Telephone:
Fax:
E-mail:
Owner’s Name:
Address:
City
St.:
Zip:
Telephone:
Fax:
E-mail:
Affidavit of Applicant
I declare under penalty of perjury under the laws of the state of Arizona that the answers I have given
are true and correct to the best of my knowledge. I also understand that the duplicate when issued is
for a single location that is listed above and is valid as long as I am appointed administrator at that
location, but for no longer than 90 days, per AAC R4-33-212.
Signature of Applicant: ________________________________
Date: ____________________
State: _____________________
County: ___________________
Subscribed and sworn to before me this ____day of ______________20 ___by the affiant, who
personally appeared before me.
______________________________
NOTARY PUBLIC SIGNATURE
My Commission expires: ____________________
(OFFICIAL STAMP)
Office Use Only
Date Requested:
Date Issued:
Duplicate #:
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