Reference Letter For Licensure As An Adult Care Home Administrator Form printable pdf download

REFERENCE LETTER FOR LICENSURE AS AN ADULT CARE HOME ADMINISTRATOR

The candidate for licensure as an adult care home administrator is required to submit two letters of reference: one from

an adult care home administrator and one from another person not related to the candidate as defined under

nepotism in K.A.R 28-38-29(h). Please use this form when submitting your reference. Mail directly to Health

Occupations Credentialing, 612 S Kansas Ave, Topeka, Kansas 66603. If you have questions, please contact Brenda

Kroll at 785-296-0061 or Brenda.Kroll@kdads.ks.gov

Candidate's Name _________________________________________________________________________

Please consider the candidate's behavior in the following areas: good judgment, integrity, honesty, fairness,

credibility, reliability, respect for others, respect for the laws of the state and nation, self-discipline, self-evaluation,

initiative, and commitment to the profession of adult care home administration and its values and ethics. Does the

candidate, in your opinion, possess the moral standards and fitness required for working as an adult care home

administrator?

Yes___

No___

If your answer is negative, explain in detail. Please relate your answer to the behavioral characteristics listed above.

____________________________________________________________________________________________

If you desire, please add any comments or information which you believe will aid the Board of Adult Care Home

Administrators in deciding to approve the candidate = s application for licensure.

____________________________________________________________________________________________

Are you a licensed adult care home administrator? ______

Are you related to the candidate as a family member or as a member of a household?_______

I attest that the information furnished above is given with the understanding that it will be utilized for purposes of

determining the candidate = s fitness for licensure as an adult care home administrator and is true and correct to the best

of my knowledge and belief.

______________

Date

_____________________________________________ ______________________________________________

Name (Please print.)

Signature

______________________________________________________________________ ______________________

Address

Phone______________________________

Email address (optional)___________________________________

Reference Letter For Licensure As An Adult Care Home Administrator Form