Application for licensure - Board of Nursing Home Administrators - nha state wy 2026

1. Click ‘Get Form’ to open the Application for licensure in the editor.
2. Begin by selecting either 'Temporary' or 'Regular Full Licensure' at the top of the form. This choice determines your application type.
3. Fill in your full name, including any previous names used, and your Social Security number in the designated fields.
4. Provide your residence address, including street, city, state, and zip code. Ensure that your telephone number is also included.
5. Next, enter your employer's information if applicable. If you have a different Wyoming employer, fill in that section as well.
6. Indicate your citizenship status and birthdate. Specify your place of birth clearly.
7. List all healthcare licenses you hold or have held in other states, detailing their current status and expiration dates.
8. Complete the education section by listing all universities attended, starting with the one from which you obtained your highest degree.
9. Provide references who will submit letters on your behalf directly to the Board.
10. Finally, answer questions regarding any disciplinary actions or convictions and attach a current photo before signing the affidavit at the end of the form.

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