Form 5 - Alabama Board of Examiners of Nursing Home ...
Appendix A – Form 5
State of Alabama Board of Examiners of Nursing Home Administrators
4156 Carmichael Road
Montgomery, Alabama 36106
(334) 271-2342
Reciprocity Questionnaire
TO THE APPLICANT:
If you are applying for the state examination for Nursing Home Administrators on the basis of your licensure in another state, please have the following certification completed by the Executive Officer of the Board of Examiners of Nursing Home Administrators of the state(s) in which you hold or have held a license as a Nursing Home Administrator.
Name
Address
TO BE COMPLETED BY STATE BOARD OFFICIAL:
Applicant's name (as shown on your records)
Address
Social Security Number
Telephone Number Home - Work -
License Number Date Issued
Expiration Date
Education: High School π College π Graduate π Post Graduate π
Please mark the highest level
State of Original License
Status of License: Active o Inactive o Expired o
Exam Score: Type: NAB o PES o Other o
Raw Score Scale Score
Date of Exam
Did applicant complete an AIT/Practicum Program in your State? Yes o No o
If yes, length of AIT/Practicum
Is applicant in good standing with your board at this time? Yes o No o
If no, please explain
Has applicant ever been disciplined by your Board? Yes o No o
If yes, please explain
Is the applicant currently being investigated for any possible criminal action or
future board disciplinary action? Yes o No o
If yes, please explain
I certify that the information provided is true and correct, according to the records of the board.
(date) (signature of executive officer)
(State Board)
(address)
(city) (state) (zip)
(area code) (telephone)
PLEASE RETURN TO:
Executive Secretary
Alabama Board of Examiners of Nursing Home Administrators
4156 Carmichael Road
Montgomery, Alabama 36106
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