Section Nuh 301.01 - Application Required(a) A person desiring to practice as a nursing home administrator within the state of New Hampshire shall make application to the board upon official forms furnished by the board, including the information specified in (b) below. The filing of an application shall not constitute temporary licensing to practice as a nursing home administrator in this state.(b) The applicant for licensure as a nursing home administrator shall provide the following on or with the "Application for a License as a Nursing Home Administrator" form: (1) Applicant's name, including any names previously used, residence address, business name and address, residence and business telephone numbers, age, birthplace, and date of birth;(2) Applicant's social security number, pursuant to RSA 161-B:11, VI-a;(3) Applicant's legal right to work status in accordance with Nuh 302.03;(4) A certified copy of National Association of Long Term Care Administrator Boards or professional examination service examination scores;(5) A completed "Administrator-In-Training Internship Evaluation Checklist" form, effective September 2018;(6) A completed "Core of Knowledge Checklist" form, effective September 2018, which lists the course work in compliance with Nuh 301.02;(7) Whether or not the applicant is licensed to practice as a nursing home administrator in any other state(s), and if yes, the state(s) and license number(s);(8) Whether or not the applicant has ever been refused a license by any examining board, and if yes, details of such refusal;(9) Whether or not the applicant has ever had a license revoked or suspended, or been placed on probation by any state board, and if yes, the details of such disciplinary action;(10) Whether or not the applicant has been convicted of a crime, fraud, neglect, or abuse that has not been annulled by a court, other than a traffic violation, and if yes, the type of violation;(11) Name(s) and addresses of college(s) attended, year(s) of attendance, degree(s) earned by applicant, and certified copies of diploma(s) and official transcript(s);(12) Applicant's employment record, including name of employer, title, employer address, specific duties, reason for leaving, total years employed, and dates employed;(13) Three original letters of recommendation, 2 professional references and one personal reference, each written within the past 12 months;(14) A "State License Clearance" form, effective September 2018, with completed personal information;(15) A photograph of the applicant; and(16) The applicant's dated signature below the following certification: I certify that there are no willful misrepresentations in and falsifications of the above statements and answers to questions. I understand that inquiry may be made of my employers, my sources of education, and of all references given about my character, qualifications, and record of employment, and if such an investigation should disclose misrepresentations and falsifications, my application will be rejected, and should I be licensed as a result of such statements, my license may be revoked.
(c) The applicant shall include the application fee specified in Nuh 307.01 which shall be cash, a check, money order or bank draft, made payable to Treasurer, State of New Hampshire.(d) Every applicant for initial permanent licensure shall submit to the board a notarized criminal history record release form, as provided by the New Hampshire division of state police, which authorizes the release of his or her criminal history record, if any, to the board.N.H. Admin. Code § Nuh 301.01
#1393, eff 7-1-79; ss by #2224, eff 1-1-83; ss by #2922, eff 12-10-84, EXPIRED: 12-10-90
New. #5097, eff 3-18-91; ss by #5326, eff 2-13-92; amd by #6466, eff 2-28-97; (a)-(c) EXPIRED: 2-13-98
New. #7663, eff 3-19-02, EXPIRED: 3-19-10
New. #9830-A, eff 12-10-10, para (a); #9830-B, eff 12-10-10, paras (b)-(d)
Amended by Volume XXXIX Number 02, Filed January 10, 2019, Proposed by #12690, Effective 12/19/2018, Expires 12/19/2028.