Board Forms

Board forms are in PDF file format and require Adobe Acrobat Reader to view. You can get this free software from the Adobe WEB site.

• Assisted Living Facility Manager Application - This form is used to apply for an Assisted Living Facility Manager certificate.  It includes information and instructions.
• Nursing Home Administrator Application - This form is used to apply for a Nursing Home Administrator License.  It includes information and instructions.
• Statement of Citizenship - This form is required for applications and renewals  It includes information and instructions.
• Application Process Flow Chart - This chart shows the steps and time frames for processing an application.
• Manager renewal Flow Chart - This chart shows the steps and time frames for processing a manager renewal
•  Individual's Application Form for Approval of a Continuing Education Class   - This form is used by Administrators or Managers who are asking the Board to approve continuing education programs are going to take or have taken.
• Continuing Education Extension Request -Between April 30, 2013 and July 31, 2013 this form is for requesting an extension of time to complete continuing education for renewal. All requirements must be met for approval.
• Sponsor Application Form for Approval of a Continuing Education Class - This form is used to get Board approval by a person or entity who will be sponsoring or teaching continuing education classes to others.
• Renewal of Sponsor of Continuing Education Course - This form is used to renew a currently approved continuing education courses that has not changed.
• Public Records Request - This form is used by people who are requesting copies of the Board's public records, including the Board's mailing lists of managers and administrators.
• Address Change - Notice of Appointment Form  - This form is used to make an address or telephone number change, and to notify the Board of a change of appointment from or to a new facility.
• Duplicate Manager License Request Form  - This form is used to request a duplicate Manager Certificate.
• Complaint Form - This form is used to file a complaint with the Board against an Assisted Living Facility Manager or a Nursing Home Administrator.
• Manager Training Application - This form is used to apply for approval of an assisted living facility manager training program.
• Caregiver Training Application  - This form is used to apply for approval of an assisted living facility caregiver training program.
• Skills Lab Assessment (sample form) - This form is a sample and can be use or modified for assessing the caregiver skills lab requirement.