Form 08-4020 - Nursing Home Administrator License Application Packet (Page 2 of 2) in pdf

APPLICATION FOR LICENSURE BY ENDORSEMENT

The division may issue a license without examination to a qualified person holding a current license as a nursing home

administrator in another jurisdiction.

The applicant must have passed the NAB/PES examination for nursing home

administrators with the minimum score recommended by NAB. In addition to items 1 and 3 – 5 above, the following must be

on file before the application can be reviewed. When the file is complete and correct in all respects, the license will be issued

and mailed with an accompanying cover letter providing further licensing information.

1. FEES - Make check or money order payable to the State of Alaska.

Nonrefundable application fee - $70

License fee - $220

2. LICENSE VERIFICATION - Original verification (p. 6) sent directly from each state in which you hold a current license.

3. EXAM RESULTS - Verified by, and sent directly from, the Professional Examination Service (PES) to this division.

PES, 475 Riverside Drive, New York, NY 10115, (212) 367-4200.

PROVISIONAL LICENSE

“A provisional license may be granted without examination to a person who meets the standards adopted by the department

under AS 08.70.050 and who is needed to fill a vacancy in an administrative position.” AS 08.70.130(a). The provisional

license is valid for six months from the date of issue and is nonrenewable.

In addition to submitting all the documents (items 1 and 3 - 5) listed under “Application for Licensure by Examination,” an

applicant for a provisional license must submit the following before a license can be issued: (1) fee of $135 ($70 nonrefundable

application fee and $65 provisional license fee), and (2) a letter from the facility where the applicant wishes to work which

states the facility’s need to immediately fill a vacant nurse home administrator position.

OTHER FEES

Wall certificate (suitable for framing), with initial application or subsequent written request ...............................................$20

Duplicate license fee (with written request) ...........................................................................................................................$5

Verification of licensure to another state (with written request) ...........................................................................................$20

Returned check fee..............................................................................................................................................................$20

Address change (must be in writing) ...............................................................................................................................no fee

GENERAL INFORMATION

APPLICATION PROCESSING - The amount of time it takes to process the application varies, depending on when all complete

and correct documents and fees are received by the division. When the application and supporting documents are received,

they are reviewed for completeness. If the application is incomplete, you will be notified of incomplete and/or incorrect

documents and fees. When the application is complete and correct, all supporting documents have been received, and all fees

have been paid, you will be notified of approval to sit for exam, or, if applying for endorsement, a license will be issued and

sent to you with an accompanying cover letter with further information about Alaska statutory requirements. If the applicant

fails the exam, additional instructions will be provided on how to request to retake it. If the application is not approved for

licensure, you will receive a written explanation of the basis of that denial and information on how to appeal the decision.

SOCIAL SECURITY NUMBERS - AS 08.01.060 and 08.01.100 require that a U.S. Social Security Number be on file with the

division before a professional license is issued or renewed for an individual. If you are a foreign citizen unable to obtain a U.S.

Social Security Number, please contact the division for further instructions.

LICENSE TERM - The professional license is a two-year license. All nursing home administrator licenses expire December 31

of even-numbered years regardless of the date of issuance. One renewal notice will be mailed at least 30 days before license

expiration to the last known address of record.

ADDRESS CHANGES - In accordance with 12 AAC 02.900, it is the applicant's/licensee's responsibility to notify the Division

of Occupational Licensing, in writing, of changes of address. The address of record with the division will be used to send

renewals and all other official notifications and correspondence.

ABANDONMENT - Under 12 AAC 02.910, an application is considered abandoned when 12 months have elapsed since

correspondence was last received from or on behalf of the applicant. An abandoned application is denied without prejudice

and the application fee is forfeited. At the time of abandonment, the division will send notification to the last known address

of the applicant, who has 30 days to submit a written request for a refund of license and other fees paid. If no request for

refund is received, all fees are forfeited.

08-4020 (Rev. 2/00)

Form 08-4020 - Nursing Home Administrator License Application Packet Page 2

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