Application for nursing home administrator license - State of New - state nj 2025

1. Click ‘Get Form’ to open the Application for Nursing Home Administrator License in the editor.
2. Begin by entering your name in the 'Name of Applicant' field. Ensure that you print or type clearly.
3. Fill in the details of the licensed long-term care facility, including its name and address. This information is crucial for your application.
4. Provide your Social Security Number, Date of Birth, and Place of Birth. If you are a U.S. citizen, check 'Yes'; otherwise, attach a copy of your green card.
5. Complete the contact information section with your home and work telephone numbers and email address.
6. Indicate if you have ever been convicted of a crime (other than traffic violations) and provide an explanation if applicable.
7. Detail your professional experience by listing employers, positions held, dates of employment, hours worked per week, and descriptions of duties.
8. List your educational background, including colleges attended and degrees obtained. Attach transcripts as required.
9. Include any professional certificates or licenses held along with their details. Attach additional sheets if necessary.
10. Finally, review all sections for accuracy before signing the certification at the end of the form.

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