Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 33 - BOARD OF EXAMINERS OF NURSING CARE ADMINISTRATORS AND ASSISTED LIVING FACILITY MANAGERS › Article 2 - NURSING CARE INSTITUTION ADMINISTRATOR LICENSING › Section R4-33-204 - Initial Application

Current through Register Vol. 30, No. 28, July 12, 2024
A. An
				individual who desires to be licensed as a nursing care institution
				administrator 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. E-mail address of the
				applicant;
5. Home, work, and
				mobile telephone numbers of the applicant;
6. Applicant's date and place of
				birth;
7. Applicant's Social
				Security number;
8. Address of
				every residence at which the applicant has lived in the last five
				years;
9. Name and address of every
				accredited college or university attended, dates of attendance, date of
				graduation, and degree or certificate received;
10. 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;
11. 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; and
e. Reason for
				employment termination;
12. 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;
13. 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;
14. 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;
15. 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;
16. 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 the suspension or
				revocation;
17. 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;
18. Whether any unresolved
				complaint against the applicant is pending with a licensing authority,
				professional association, health care facility, or nursing care institution and
				if so, the nature of and where the complaint is pending;
19. 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
20. Whether
				the applicant ever was pardoned from or had expunged the record of a felony
				conviction and if so, the nature of the offense, jurisdiction, and date of
				pardon or expunging.