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

Universal Citation: AZ Admin Code R 4-33-204

Current through Register Vol. 30, No. 38, September 20, 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.

B. In addition to the application form required under subsection (A), an applicant shall have the following submitted directly to the Board on the applicant's behalf:

1. Official transcript submitted by each accredited college or university attended by the applicant;

2. Verification of license that is signed, authenticated by seal or notarization, and submitted by each agency that ever issued a professional license to the applicant;

3. "Character Certification" form submitted by two individuals who have known the applicant for at least three years and are not related to, employed by, or employing the applicant; and

4. If the applicant is certified by ACHCA, verification of certification submitted by ACHCA;

C. In addition to complying with subsections (A) and (B), an applicant shall submit:

1. If the applicant completed an AIT program, a photocopy of the certificate issued upon completion;

2. For every felony or misdemeanor charge listed under subsection (A)(19), a copy of documents from the appropriate court showing the disposition of each charge;

3. For every felony or misdemeanor conviction listed under subsection (A)(19), a copy of documents from the appropriate court showing whether the applicant met all judicially imposed sentencing terms;

4. Full-face photograph of the applicant taken within the last six months;

5. Fingerprint clearance card.
a. Photocopy of the front and back of the applicant's fingerprint clearance card and has not been convicted of a felony involving violence or financial fraud,

b. Proof of submission of an application for a fingerprint clearance card and has not been convicted of a felony involving violence or financial fraud, or

c. If denied a fingerprint clearance card, proof the applicant qualifies for a good-cause exception hearing under A.R.S. § 41619.55 and has not been convicted of a felony involving violence or financial fraud;

6. A full set of fingerprints taken by a law enforcement agency or other authority acceptable to the Board and in a format acceptable to the Arizona Department of Public Safety and the Federal Bureau of Investigation and the amount charged by the Arizona Department of Public Safety to process the fingerprints for a state and federal criminal history records check;

7. Documentation, as described in A.R.S. § 41-1080(A), of U.S. citizenship or alien status indicating presence in the U.S. is authorized under federal law;

8. Affirm the information provided in the application is true and complete and authorize others to release information regarding the applicant to the Board; and

9. Fees required under R4-33-104(A)(1) and (A)(2).

D. If required by the Board under A.R.S. § 36-446.03(D), an applicant shall appear before the Board.

E. When the information required under subsections (A) through (C) is received and following an appearance before the Board required under subsection (D), the Board shall provide notice regarding whether the applicant may take the licensing examinations required under R4-33-201 or R4-33-202.

F. Because of the time required for the Board to perform an administrative completeness review under R4-33-103, an applicant shall ensure the information required under subsections (A) through (C) is submitted at least 30 days before the applicant expects to take the Arizona examination.

Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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