Application For Temporary Adult Care Home Administrator License
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2KANSAS DEPARTMENT FOR AGING AND DISABILITY SERVICES
Board of Adult Care Home Administrators
APPLICATION FOR
TEMPORARY Adult Care Home Administrator License
TYPE OF LICENSE
G TEMPORARY: $100.00
Personal checks are accepted; license may be subject to action if checks are found invalid or insufficient. Visa or MasterCard may be
used for payment of fees. Charge authorization form must be completed and signed to utilize this option.
APPLICANT INFORMATION
Name:
Last
First
Mi
Other
Address:
Street / Route / Box / Apt #
City
State
Zip
Phone: work (
)
home (
)
Birthdate:
/
/
SSN
___________
Email address (optional) _________________________________________ ______________________________________________
(attach a copy of your Social Security Card or document bearing your name and Social Security number)
FACILITY IN WHICH YOU ARE SEEKING EMPLOYMENT:
FacilityName:
Facility Phone: (
)
___
Address:
_____
Street / Route / Box / Apt #
City
State
Zip
EDUCATION
- List
College/University
Degree
Date Conferred
1.
_
2.
_
3.
_
If applicable, transcripts must be sent by the college or university directly to Health Occupations Credentialing. If you are filing for testing
under KSA-65-3504(b), request, complete, and submit Application for Exemption of Formal Education.
FUTURE PLANS
I will seek full licensure.
Y / N
I will plan to seek licensure based on licensure in another state.
Y / N
I have held a license as a Kansas Adult Care Home Administrator.
Y / N
If YES, License Number:
Issue Date:
Expiration Date:
I have at least once failed the examination specified in KAR 28-38-18.
Y / N Exam Date _
LICENSE IN ANOTHER STATE
List all states in which you have ever held an adult care home administrator license:
State:
State:
State:
State:
State:
State:
For each state, complete Part I of the verification of license, request that the state Board complete Part II and return verification to this
Board.
DOCUMENTATION OF NEED FOR TEMPORARY LICENSE
K.A.R. 28-38-21 requires that applicants provide written documentation from the board of directors, corporation or ownership of the facility
that no licensed, qualified applicant is available to serve as administrator in the facility and written endorsement that the applicant is the
most qualified applicant for the facility where the person is to be employed.
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