Cdph 503 - Application For Nursing Home Administrator State Examination

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State of California – Health and Human Services Agency

California Department of Public Health (CDPH)

Nursing Home Administrator Program (NHAP)

P.O. BOX 997416, MS 3302

Sacramento, CA 95899-7416

(916) 552-8780 FAX: (916) 552-8777

NHAP@cdph.ca.gov

APPLICATION FOR NURSING HOME ADMINISTRATOR

STATE EXAMINATION

Return this completed form with a check or money order (made payable to NHAP) with the appropriate fees

(Application Processing Fee and Written State Exam Fee) to the following address:

Nursing Home Administrator Program

P.O. Box 997416, MS 3302

Sacramento, CA 95899-7416

For a current Fee List and Detailed Fee Analysis, please visit our website at:

APPLICANT’S NAME (Last)

(First)

(M.I.)

SOCIAL SECURITY NUMBER*

MAILING ADDRESS (Number)

(Street)

WORK TELEPHONE NUMBER

(City)

(County)

(State)

(Zip Code)

HOME TELEPHONE NUMBER

E-MAIL ADDRESS

DRIVER’S LICENSE NUMBER

DATE OF BIRTH (MM/DD/YYYY)

*Social Security Number Disclosure: Pursuant to Section 666(a)(13) of Title 42 of the United States Code and California Family Code section 17520, subdivision (d), the CDPH is required to collect social security numbers

from all applicants for nursing home administrator licenses. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support orders upon request by the Department

of Child Support Services, collection of delinquent State taxes if applicant appears on the Franchise Tax Board’s top 500 delinquent taxpayers list pursuant to Business Codes Section 494.5 Subdivision (4) and for reporting

disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR, Section 61.1 et seq. Failure to provide your social security number will result in the return of your application. Your social

security number will be used by CDPH for internal identification, and may be used to verify information on your application, to verify certification with another state’s certification authority, for exam identification, for

identification purposes in national disciplinary databases or as the basis of a disciplinary action against you.

Have you ever pled guilty or nolo contendere to, or been convicted of, any crime (other than minor traffic violations)?

YES**

** IF THE ANSWER TO THIS QUESTION IS “YES”, EXPLAIN FULLY ON A SEPARATE SHEET OF PAPER. PROVIDE CERTIFIED COPIES OF ARREST REPORT AND COURT DOCUMENTS

THAT INCLUDE THE FOLLOWING AS APPLICABLE: CRIMINAL COMPLAINT, PLEA AND JUDGMENT, AND PROBATION REPORT. IF THESE RECORDS HAVE BEEN DESTROYED, THE

PROGRAM REQUIRES A SIGNED STATEMENT TO THAT FACT FROM THE AGENCY YOU ARE REQUESTING YOUR INFORMATION. A CONVICTION WILL NOT NECESSARILY DISQUALIFY

YOU.

Check box only if you require special accommodation. If so, please submit the Special Accommodation Request for Examination (CDPH 523) form

with this application.

I am enclosing a check or money order in the amount of $________

Requested Exam Date __________________________________

CITIZENSHIP (Health and Safety Code 1416.22 (a))

(a) Are you a United States Citizen?

Yes

(b) Are you a Legal Resident?

Yes

(c)

Are you at least eighteen (18) years of age or older?

Yes

AN APPLICANT’S ELIGIBILITY FOR LICENSURE SHALL BE DEPENDENT ON SUCCESSFUL COMPLETION OF THE NATIONAL AND STATE EXAMINATIONS.

FAMILY SUPPORT

In accordance with the Welfare and Institutions Code Section 11350.6, applications for renewal of a license or a new license shall include the applicant's Social Security Number, and the

licensee shall certify, under penalty of perjury, that he or she is not more than thirty (30) days delinquent in complying with a child support order, order for spousal support or alimony. Failure

to certify may result in disciplinary or adverse action, and making a false statement may subject the licensee's license to denial or revocation actions by NHAP.

You must check one of the following:

I am not more than ____ days delinquent in complying with a child support order/order for spousal support or alimony/education loan replacement obligation.

I am more than ____ days delinquent in complying with a child support order/order for spousal support or alimony/education loan replacement obligation.

I am currently in compliance with a family support order.

I am not currently under any child or family support order repayment obligation.

CERTIFICATION – IMPORTANT – PLEASE READ BEFORE SIGNING – If not signed, this application may be rejected.

I certify under the penalty of the perjury laws of the State of California that the information I have entered on this application is true and correct to the best of my knowledge. I further understand that any

false, incomplete, or incorrect statements may result in denial of this application with the Nursing Home Administrator Program. I understand that if I fail to appear for the examination as scheduled, the

fees are non-refundable and non-transferable and will be forfeited.

APPLICANT’S SIGNATURE : _______________________________________________________________________________________

DATE SIGNED : ______________________

APPLICANTS—DO NOT USE THIS SPACE BELOW—FOR NHAP USE ONLY

STATUS

CASH # _____________________________

Approved

Rejected

Denied

Training Requirements

AIT #

NHAP INITIALS _______________________

STAFF

DATE PROCESSED

AMOUNT ______________________

All information requested by the application is required by the California Department of Public Health, Nursing Home Administrator Program. Maintenance of the information requested on this form is authorized by the

Health and Safety Code.

CDPH 503 (05/14)