State Form 8200 - Application For License To Operate A Health Faclity - Indiana State Department Of Health Page 2
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4SECTION III – STAFFING
A. Administrator
Name (enter full name)
Indiana License Number (please include a copy of license with application)
Date of Birth
Date employed in this position
1.
List post secondary education and health related experience
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
2.
On a separate sheet, list the facilities in Indiana, or any other state, in which the Administrator has been previously employed, including the
dates of employment and reason for leaving. Identify on this list any of these facilities which were operating with less than a full license at the
time the Administrator was employed.
• •
• •
3.
Has the administrator ever been convicted of any criminal offense related to a dependent population?
Yes
No
(If yes, state on a separate sheet the facts of each case completely and concisely)
• •
• •
4.
Has the administrator’s license ever lapsed, been suspended or revoked?
Yes
No
(If yes, state on a separate sheet the facts of each case completely and concisely)
5.
Is the administrator presently in good health and physically able to fully carry out all of the duties in the operation of this health facility?
• •
• •
Yes
No
(If no, explain on a separate sheet)
B. Director of Nursing
Name (enter full name)
Indiana License Number (please include a copy of license with application)
Date of birth
Date employed in this position
Education (Name of School of Nursing)
School Degree
Year Graduated
Other College Education
Qualifications or Experience
• •
• •
1. Has the Director of Nursing ever been convicted of any criminal offense related to a dependent population?
Yes
No
)
(If yes, state on a separate sheet the facts of each case completely and concisely
• •
• •
2. Has the Director of Nurse’s License ever lapsed, or ever been suspended or revoked?
Yes
No
)
(If yes, state on a separate sheet the facts of each case completely and concisely
SECTON IV - DISCLOSURE OF OWNERSHIP AND CONTROLLING INTEREST STATEMENT
(In compliance with the Indiana Health Facilities Rules (410 IAC 16.2)
A. Applicant Entity
Name of Applicant Entity (operator(s) of the facility)
D/B/A ( Name of Facility)
B. Ownership Information
List names and addresses of individuals or organizations having direct or indirect ownership interest of five percent (5%) or more in the
applicant entity. Indirect ownership interest is interest in an entity that has an ownership interest in the applicant entity. Ownership in
any entity higher in a pyramid than the applicant constitutes indirect ownership. (use additional sheet if necessary)
Name
Business Address
EIN Number
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