Form 08-4020 - Nursing Home Administrator License Application (Page 2 of 2) in pdf

LICENSE HISTORY - List all current and previous nursing home administrator licenses held in any jurisdiction and provide

verification of licensure from each jurisdiction in which you hold or have held a license. If none, state N/A.

Original

By Examination/

Jurisdiction

License #

Date of Issue

Status

Reciprocity

EXAMINATION - If applying by Endorsement, list name of exam taken; have verification of your score from the Professional

Examination Service (PES) sent directly to Alaska.

Exam Name/Date Taken

PROFESSIONAL FITNESS - If you answer "yes" to any of the following questions, explain fully in a separate, signed affidavit

and attach applicable documentation, i.e., court records, etc.

YES

1. Has your professional license ever been denied, revoked, suspended, surrendered, stipulated, on

probation or been subject to any other restriction or disciplinary action in any jurisdiction? .....................

2. Have you been or are you under investigation by any state board or agency for alleged misconduct? ...

3. Have you been convicted of any criminal offense other than a minor traffic violation?.............................

4. Within the past five years, have you experienced or been treated for bipolar disorder, schizophrenia,

paranoia, psychotic disorder, or substance abuse? ..................................................................................

5. Within the past five years, have you been addicted to, excessively or illegally used alcohol, or a

controlled substance?................................................................................................................................

6. Within the past five years, have you experienced a physical disability which may impair or interfere with

your ability to practice as a Nursing Home Administrator?........................................................................

Please be aware that all information on this application form will be available to the public, unless required to be kept

confidential by state or federal law.

I certify that the information in this application is true and correct to the best of my knowledge. I further certify that all

credentials and supporting documents supplied by me are true and correct and that the photograph below is a true likeness

of me taken within the past 60 days. I understand that any false information or falsification of documents may result in failu re

to obtain, or subsequent revocation of, a license to practice as a nursing home administrator in Alaska.

Signature of Applicant

Sign Here

Current Head and Shoulders

SUBSCRIBED AND SWORN TO before me on

Photograph

(date).

Notary Public, State of

My Commission Expires:

(NOTARY SEAL)

NOTE: NOTARY PUBLIC SEAL MUST OVERLIE A PORTION OF THE PHOTOGRAPH

08-4020 (Rev. 2/00)

(2)

Form 08-4020 - Nursing Home Administrator License Application Page 2