Adult Care Home Administrator Licensure Renewal Application Form
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1Adult Care Home Administrator Licensure Renewal Application
Your Adult Care Home Administrator license will expire June 30, 2016. Renewal materials must be
postmarked by June 30, 2016 to avoid a $50.00 late fee.
License #: __________________
Lic. End Date: June 30, 2016
CE Hrs Due: See Instruction Sheet
Name_____________________________
Renewal Fee: $100.00
Address___________________________
City, State, Zip______________________
NOTE: ONLY use this application form if NOT using the online renewal process.
Disciplinary History:
During this licensure period, has your license, certification, or registration issued by Kansas or another state or
entity been denied, refused for renewal, suspended, revoked, or subjected to any disciplinary action, or have you
been convicted of a crime by any state or federal court in the United States?
[
] No
[
] Yes (attach explanation)
Note: According to KSA 65-3505(d) and established board policy, a random check for criminal history will be made on renewal applications.
Continuing Education Attestation
The following attestation statement regarding continuing education must be signed to renew your license:
By signing this application, I affirm that I have completed the continuing education required by regulation
(KAR 28-38-23). I understand that an audit will be conducted of a percentage of all applications, and should
my application be subject to audit, I will provide all documentation as requested. I understand that my
license will not be renewed until all required documentation is reviewed and approved. I also know that
falsifying any of this documentation may result in disciplinary action against my license.
Signature
Date ___________________
If NOT renewing please indicate below:
I do not intend to renew my Kansas Adult Care Home Administrator license at this time because:
________________________________________________________________________________
(Please return this application to the address below so we can update your records)
Before mailing your renewal application, be sure that you have:
Enclosed a non-refundable fee of $100 made payable to KDADS; or completed and enclosed the
authorization form to charge fees to your Visa or MasterCard.
Answered the disciplinary question.
Signed the continuing education attestation.
NOTE: As mentioned above, applications postmarked after 06-30-2016 and before 07-30-2016 can still
be processed for renewal if the required CE was obtained by 06-30-2016, but a $50 late fee must be paid in
addition to the $100 renewal fee. After 07-30-2016, licenses are considered lapsed and would have
to be reinstated. The fee for reinstatement is $220.
Health Occupations Credentialing ● 612 S Kansas Ave ● Topeka, KS 66603
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