Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 33 - BOARD OF EXAMINERS OF NURSING CARE ADMINISTRATORS AND ASSISTED LIVING FACILITY MANAGERS › Article 4 - ASSISTED LIVING FACILITY MANAGER CERTIFICATION › Section R4-33-403 - Initial Application

Current through Register Vol. 30, No. 28, July 12, 2024
A. An
				individual who desires to be certified as a manager of an assisted living
				facility shall submit the following information to the Board on an application
				form, which is available from the Board:
1.
				Full name of the applicant;
2.
				Other names that the applicant has used;
3. Mailing address of the
				applicant;
4. Home, work, and
				mobile telephone numbers of the applicant;
5. Applicant's date and place of
				birth;
6. Applicant's Social
				Security number;
7. Address of
				every residence at which the applicant has lived in the last five
				years;
8. Education information
				regarding the applicant, including:
a. Name
				and location of last high school attended;
b. Date of high school graduation or date on
				which a G.E.D. was earned; and
c.
				Name and address of every accredited college or university attended, dates of
				attendance, date of graduation, and degree or certificate earned;
9. Information regarding
				professional licenses or certifications currently or previously held by the
				applicant, including:
a. Name of issuing
				agency;
b. License or certificate
				number;
c. Issuing
				jurisdiction;
d. Date on which the
				license or certificate was first issued;
e. Whether the license or certificate is
				current; and
f. Whether the license
				or certificate is in good standing and if not, an explanation;
10. Information regarding the
				applicant's employment record for the last five years, including:
a. Name, address, and telephone number of
				each employer;
b. Title of position
				held by the applicant;
c. Name of
				applicant's supervisor;
d. Dates of
				employment;
e. Number of hours
				worked each week;
f. Whether the
				employment was full or part time; and
g. Reason for termination;
11. Whether the applicant was ever
				denied a professional license or certificate and if so, the kind of license or
				certificate denied; licensing authority making the denial, and date;
12. Whether the applicant ever voluntarily
				surrendered a professional license or certificate and if so, the kind of
				license or certificate surrendered, licensing authority, date, and reason for
				the surrender;
13. Whether the
				applicant ever allowed a professional license or certificate to lapse and if
				so, the kind of license or certificate that lapsed, licensing authority, date,
				reason for lapse, and whether the license or certificate was
				reinstated;
14. Whether the
				applicant ever had a limitation imposed on a professional license or
				certificate and if so, the kind of license or certificate limited, licensing
				authority, date, nature of limitation, reason for limitation, and whether the
				limitation was removed;
15. Whether
				the applicant ever had a professional license or certificate suspended or
				revoked and if so, the kind of license or certificate suspended or revoked,
				licensing authority, date, and reason for suspension or revocation;
16. Whether the applicant ever was subject to
				disciplinary action with regard to a professional license or certificate and if
				so, the kind of license or certificate involved, licensing authority, date, and
				reason for and nature of the disciplinary action;
17. Whether any unresolved complaint against
				the applicant is pending with a licensing authority, professional association,
				health care facility, or assisted living facility and if so, the nature of and
				where the complaint is pending;
18.
				Whether the applicant ever was charged with or convicted of a felony or a
				misdemeanor, other than a minor traffic violation, in any court and if so, the
				nature of the offense, jurisdiction, and date of discharge; and
19. Whether the applicant ever was pardoned
				from or had the record expunged of a felony conviction and if so, the nature of
				the offense, jurisdiction, and date of pardon or expunging.