Form 08-4020 - Nursing Home Administrator License Application Packet

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Alaska Department of Community and Economic Development
Division of Occupational Licensing
Nursing Home Administrator Section
P.O. Box 110806, Juneau, Alaska 99811-0806
333 Willoughby Avenue, 9th Floor, Juneau, Alaska 99801-0800
(907) 465-2695
E-mail: license@dced.state.ak.us
NURSING HOME ADMINISTRATOR LICENSE APPLICATION PACKET
“Only a licensed nursing home administrator may manage, supervise, or be generally in charge of a nursing home. The care
provided by a nursing home or a licensed hospital providing nursing home care through the use of skilled nursing beds or
intermediate care beds shall be supervised by a licensed nursing home administrator . . . .” AS 08.70.080
GENERAL INSTRUCTIONS
Please read the application and all the instructions carefully. It is the applicant's responsibility to completely and accurately
fill out the application and submit all required supporting documents. If the supporting documents show a name other than the
one on the application (e.g., because of marriage, divorce, or any other reason), include an explanation and a certified true
copy of the document that supports that change. Incomplete or incorrect documents will be returned and will cause delays
in processing the application. Please type or print all requested data. If space for any answer is insufficient, use an additional
sheet and specify the question to which it relates.
All documents must be originals or certified true copies of the original documents. To obtain a certified true copy, take the
original documents and the photocopies to a notary public so s/he can compare each original document to its copy. Write or
type "true copy of the original" on the photocopy and have the notary attest to its authenticity by including the notary's signature

and seal. Documents of not larger than 8-
" x 11" are preferred.
If applying for licensure by examination, please note that the Professional Examination Service (PES) exam is offered year-
round, as scheduled, via Computer-Based Testing (CBT) beginning January 2000. To apply to sit for examination, complete
the state’s application, provide all supporting documents, and pay the application and license fees; check or money order made
payable to the State of Alaska. Upon application approval, you will be sent the Exam Information for Candidates booklet,
NAB/PES scannable application, and further information regarding sitting for the exam.
APPLICATION FOR LICENSURE BY EXAMINATION
The following documents and fees must be on file with the division before the file will be reviewed:
1. APPLICATION - completed, signed, and notarized, including a recent head and shoulders photograph. The notary's
seal must overlie a portion of the photograph. Applicant must be a minimum of 19 years of age as shown on the
signed and notarized application.
2. FEES - Make check or money order payable to the State of Alaska.
Nonrefundable application fee - $70
License fee - $220
Make certified check or money order payable to NAB (National Association of Boards of Examiners of Long-Term Care
Administrators); personal checks are not accepted – Exam and CBT fees - $235.
3. EDUCATION - An official transcript from a bachelor’s or higher degree in a health care or business-related field from
a college or university accredited by a national or regional accredited association recognized by the United States
Secretary of Education.
4. A. EXPERIENCE - Work Experience Verification form (p. 3) completed by present or past supervisor(s) to document
a minimum of 12 months of experience in health care facility management; OR
B. TRAINING - Administrator-in-Training (AIT) verification form (p. 5) that meets Alaska’s criteria or verifies
completion of an AIT program approved by another jurisdiction, and AIT Program Proposal form (p. 4).
5. RELEASE - Completed Authorization to Release Records form (p. 7).
08-4020 (Rev. 2/00)
CONTINUED ON REVERSE

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