Section 449.818 - Contents of application for provisional certificate; fee1. An application for a provisional license must be submitted to the Division on a form furnished by the Division accompanied by a nonrefundable fee of $100 and must include: (a) For an applicant who is a natural person: (1) Three or more letters of professional reference;(2) A certification, signed by the applicant, that the applicant will maintain the confidentiality of information relating to any person who receives services;(3) Proof that the applicant has successfully completed a course in cardiopulmonary resuscitation according to the guidelines of the American Red Cross or American Heart Association;(4) Proof that the applicant is currently certified in standard first aid through a course from the American Red Cross or American Heart Association or, if the applicant submits proof that the course meets or exceeds the requirements of the American Red Cross or the American Heart Association, an equivalent course in standard first aid;(5) Written verification, on a form prescribed by the Division, that the fingerprints of the applicant were taken and forwarded electronically or by another means directly to the Central Repository for Nevada Records of Criminal History and that the applicant has given written permission to the law enforcement agency or other authorized entity taking the fingerprints to submit the fingerprints to the Central Repository for submission to the Federal Bureau of Investigation and to such other law enforcement agencies as the Division deems necessary for reports on the applicant's background to the Division and the applicant;(6) A copy of the social security card of the applicant;(7) A copy of a form of government-issued identification, which may include, without limitation, a passport, identification card or driver's license;(8) An attestation that the applicant has sufficient working capital to effectively provide services and, if the applicant proposes to provide services in a facility, operate the facility;(9) If applicable, a copy of the applicant's state business license and a copy of the current business license issued for the applicant's business by the county, city or town in which the applicant's business is located or written verification that the applicant is exempt from any requirement to obtain a business license; and(10) Any other information required by the Division.(b) For an applicant other than a natural person:(1) If applicable, a copy of the state business license of the organization and a copy of the current business license issued for the applicant's business by the county, city or town in which the applicant's business is located or written verification that the applicant is exempt from any requirement to obtain a business license;(2) The federal tax identification number of the organization;(3) A copy of the bylaws, articles of incorporation, articles of association, articles of organization, partnership agreement, constitution and any other substantially equivalent documents of the applicant, and any amendments thereto;(4) A list of the members of the governing body of the applicant;(5) If the applicant is an association or a corporation: (I) The name, title and principal business address of each officer and member of its governing body;(II) The signature of the chief executive officer or an authorized representative; and(III) If the applicant is a corporation, the name and address of each person holding more than 10 percent of its stock;(6) For each member of the governing body:(I) Three or more letters of professional reference; and(II) Written verification, on a form prescribed by the Division, that the fingerprints of the member of the governing body were taken and forwarded electronically or by another means directly to the Central Repository for Nevada Records of Criminal History and that the member of the governing body has given written permission to the law enforcement agency or other authorized entity taking the fingerprints to submit the fingerprints to the Central Repository for submission to the Federal Bureau of Investigation and to such other law enforcement agencies as the Division deems necessary for reports on the member's background to the Division and the applicant;(7) An attestation that the applicant has sufficient working capital to effectively provide services and, if the applicant proposes to provide services in a facility, operate the facility;(8) Copies of any policies and procedures of the applicant relating to the provision of services; and(9) Such other information as may be required by the Division.2. An applicant for a provisional license shall post a surety bond in an amount equal to the operating expenses of the applicant for 2 months, place that amount in escrow or take another action prescribed by the Division to ensure that, if the applicant becomes insolvent, recipients of community-based living arrangement services from the applicant may continue to receive community-based living arrangement services for 2 months at the expense of the applicant.3. As used in this section: (a) "Electronic signature" means a user name attached to or logically associated with a record and executed or adopted by a person with the intent to sign an electronic application or other document.(b) "Signature" includes, without limitation, an electronic signature.Nev. Admin. Code § 449.818
(Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)-(Substituted in revision for NAC 433.330); A by R048-22A, eff. 12/29/2022