Form CDPH506 "Application for Nursing Home Administrator License" - California

What Is Form CDPH506?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2014;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH506 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH506 "Application for Nursing Home Administrator License" - California

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State of California – Health and Human Services Agency
California Department of Public Health (CDPH)
Nursing Home Administrator Program (NHAP)
MS 3302, P.O. BOX 997416
Sacramento, CA 95899-7416
(916) 552-8780 FAX: (916) 552-8777
NHAP@cdph.ca.gov
APPLICATION FOR NURSING HOME ADMINISTRATOR LICENSE
Return this completed form with a cashier’s check or money order (made payable to NHAP) with the appropriate fees to the following address:
Nursing Home Administrators Program
P.O. Box 997416, MS 3302
Sacramento, CA 95899-7416
www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/NHAPFees.aspx
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
DRIVER’S LICENSE NUMBER
E-MAIL ADDRESS
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 California Department of Public Health (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
NO
**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.
I am enclosing a cashier’s check or money order in the amount of $________
CITIZENSHIP (Health and Safety Code 1416.22 (a))
(a) Are you a United States Citizen?
Yes
No
(b) Are you a Legal Resident?
Yes
No
(c)
Are you at least eighteen (18) years of age or older?
Yes
No
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 on 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 current 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 NHAP. 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, NHA). Maintenance of the information requested on this form is authorized by the Health and Safety Code. Failure to
provide any of the required information will result in the application being rejected as incomplete. For more information or access to records containing your personal information maintained by CDPH, contact the
NHAP, P.O. Box 997416, MS 3302, Sacramento, CA 94899-7416, (916) 552-8780.
CDPH 506 (05/14)
State of California – Health and Human Services Agency
California Department of Public Health (CDPH)
Nursing Home Administrator Program (NHAP)
MS 3302, P.O. BOX 997416
Sacramento, CA 95899-7416
(916) 552-8780 FAX: (916) 552-8777
NHAP@cdph.ca.gov
APPLICATION FOR NURSING HOME ADMINISTRATOR LICENSE
Return this completed form with a cashier’s check or money order (made payable to NHAP) with the appropriate fees to the following address:
Nursing Home Administrators Program
P.O. Box 997416, MS 3302
Sacramento, CA 95899-7416
www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/NHAPFees.aspx
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
DRIVER’S LICENSE NUMBER
E-MAIL ADDRESS
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 California Department of Public Health (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
NO
**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.
I am enclosing a cashier’s check or money order in the amount of $________
CITIZENSHIP (Health and Safety Code 1416.22 (a))
(a) Are you a United States Citizen?
Yes
No
(b) Are you a Legal Resident?
Yes
No
(c)
Are you at least eighteen (18) years of age or older?
Yes
No
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 on 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 current 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 NHAP. 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, NHA). Maintenance of the information requested on this form is authorized by the Health and Safety Code. Failure to
provide any of the required information will result in the application being rejected as incomplete. For more information or access to records containing your personal information maintained by CDPH, contact the
NHAP, P.O. Box 997416, MS 3302, Sacramento, CA 94899-7416, (916) 552-8780.
CDPH 506 (05/14)