Application For Temporary Adult Care Home Administrator License Page 2

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DISCIPLINARY ACTION
Has disciplinary action ever been taken against an adult care home administrator license, a professional or occupational health care
license, a mental health care license or a social worker license held by you, whether issued by this state or another state or jurisdiction?
Y / N
If YES, please provide specific details and copies of all relevant documents.
__ ______
Please read carefully before answering
Have you ever been convicted of a crime by any court (including Kansas), or any federal court of the United States? This includes any
felony, misdemeanor, or DUI convictions.
Y / N
If YES, please indicate:
Date of conviction:
City, County and state of conviction:
Crime of which convicted:
NOTE: Pursuant to state regulations, the Board requires that you provide all reports and court documents related to the conviction.
Materials should be submitted to Health Occupations Credentialing. Please note, any and all costs for obtaining such reports/documents
are your responsibility. You are also invited to submit a letter and any other additional supporting information or documents to the Board
explaining the circumstances surrounding the case, complete resolution of the issue (including final probation, community corrections or
parole documents), and how/why this situation is not expected to occur again. The candidate shall have the burden of proving that the
candidate has been rehabilitated and warrants the public trust.
I do hereby attest that the information supplied in this application and any attachment is accurate and complete to the best of my
knowledge. I do hereby give permission to the Board to verify any information provided in this application and attachments. I understand
that the application fee is non-refundable should I not meet licensure qualifications.
Signature:
Date:
PLEASE NOTE:
YOUR SIGNATURE MUST BE NOTARIZED
Subscribed and sworn to me the undersigned
on this __________day of ____________________, 201__________
__________________________________________________________
(Notary Public)
My appointment expires:______________________________________
Submit application, fee and supporting documents to:
Health Occupations Credentialing
Kansas Department for Aging and Disability Services
612 S Kansas Ave
Topeka, Kansas 66603

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