Form 08-4020 - Nursing Home Administrator License Application
ADVERTISEMENT
1
2NHA
Alaska Department of Community and Economic Development
Division of Occupational Licensing
Nursing Home Administrator Section
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2695
E-mail: license@dced.state.ak.us
NURSING HOME ADMINISTRATOR LICENSE APPLICATION
$ 70 Nonrefundable application fee
$220 License fee
$65 Provisional license fee
$235 Exam/CBT fees – separate certified check or money order payable to NAB
Application for licensure:
by Examination
by Endorsement
for Six Months Provisional
Name
Last
First
Middle
Maiden/Other
Social Security Number
Birthdate
Sex:
Mailing Address
City
State
ZIP Code
Residence Address
City
State
ZIP Code
Telephone - Business
Home
EDUCATIONAL HISTORY - List accredited college or university attended where bachelor’s or higher degree in a health-care
or business-related field was received; have official transcript(s) sent directly to Alaska.
Name of School
Location
From
To
Degree/Date
Mo./Yr.
Mo./Yr.
Awarded
EMPLOYMENT - List employment experience in institutional management in a health care facility. Management experience
must be a minimum of 12 months in which an applicant earned at least 40 hours of experience in each month. The experience
must include general administration techniques; fiscal, personnel, and physical facility management; client care issues; federal
and state regulations; and public relations. The 12 months’ experience need not be consecutive.
How many years of experience do you have in health care institutions?
TRAINING - Provide information regarding Administrator-In-Training (AIT) program attended.
Location of
Duration of
Name of Preceptor
Training
Program
Starting Date
Completion Date
Department Use Only
License No.
Issue Date
Expiration Date
12/31/
08-4020 (Rev. 2/00)
(1)
CONTINUED ON REVERSE
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal