THE KENTUCKY BOARD OF LICENSURE FOR NURSING HOME ADMINISTRATORS INACTIVE RENEWAL FORM
PO BOX 1360 FRANKFORT, KY 40602 502-564-3296 x227 http://dop.ky.gov/nha
FEE: $50.00 inactive LIC NO: KY -
Your license expires: In accordance with KRS Chapter 2l6A and regulations governing this profession, you are required to renew your inactive license every two (2) years with the submission of this form and an inactive renewal fee of $50.00 by check or money order made payable to the Kentucky State Treasurer. DO NOT SEND CASH. Licenses not renewed by the end of the 60 day grace period will be terminated and you must immediately CEASE AND DESIST. If you wish your inactive license to become active, please submit a written request along with copies of your continuing education certificates and this form for board review. PLEASE COMPLETE THE FOLLOWING: l. Note changes only if different from above: Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________ 2. Present Business Name/Address: (REQUIRED) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 3. Home Phone ( ) ____________________ Business Phone ( ) _______________________
4. Social Security Number: _____-_____-_____ 5. E-Mail Address: ______________________________________ 6. Have you been convicted of a felony or misdemeanor since the last renewal of your license? ( ) No ( ) Yes If yes, what offense and give details _____________________________________________________________ 7. Has your license to be a Nursing Home Administrator in KY or any other state been subject to disciplinary action? ( ) No ( )Yes. If yes, give details and submit necessary documentation to the board for review. ____________ LICENSEE AFFIDAVIT I, the licensee named in the above, do certify under penalty of law that the information contained herein is true, correct, and complete to the best of my knowledge and belief. I am aware that, should investigation at any time disclose any such misrepresentation or falsification, my license could be subject to disciplinary action by the Kentucky Board of Licensure for Nursing Home Administrators.
Date: ______________________Applicant's Signature________________________________________________ (Sign your name - Do not print or type)
You may also renew online at http://dop.ky.gov/nha under online renewal.