Form CDPH503 "Application for Nursing Home Administrator Licensing Examination" - California

What Is Form CDPH503?

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 January 1, 2020;
  • 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 CDPH503 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form CDPH503 "Application for Nursing Home Administrator Licensing Examination" - California

Download PDF

Fill PDF online

Rate (4.3 / 5) 11 votes
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) 636-6108
NHAP@cdph.ca.gov
APPLICATION FOR NURSING HOME ADMINISTRATOR
LICENSING EXAMINATION
This application is intended for those who have completed an Administrator-in-Training program and are applying for the
licensing examination for the first time. The nursing home administrator licensing examination consists of a written state
examination and an online national examination. Approval of this application grants you approval for your first attempt for both.
Return this completed form with a check or money order (made payable to NHAP) with the appropriate fees to the following address:
Nursing Home Administrator Program
P.O. Box 997416, MS 3302
Sacramento, CA 95899-7416
https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/NHAPFees.aspx
For a current Fee List and Detailed Fee Analysis, please visit our website at:
SOCIAL SECURITY NUMBER
(M.I.)
(First)
APPLICANT’S NAME (Last)
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)
Requested State Exam date: __________________________________
Please note, the National Exam is self-scheduled and instructions for completing registration will be mailed upon approval of this application.
Check box only if you require special accommodations during the examination. If special accommodations are required, please provide an
explanation below.
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
NHAP INITIALS _______________________
AIT #
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 (01/20)
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) 636-6108
NHAP@cdph.ca.gov
APPLICATION FOR NURSING HOME ADMINISTRATOR
LICENSING EXAMINATION
This application is intended for those who have completed an Administrator-in-Training program and are applying for the
licensing examination for the first time. The nursing home administrator licensing examination consists of a written state
examination and an online national examination. Approval of this application grants you approval for your first attempt for both.
Return this completed form with a check or money order (made payable to NHAP) with the appropriate fees to the following address:
Nursing Home Administrator Program
P.O. Box 997416, MS 3302
Sacramento, CA 95899-7416
https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/NHAPFees.aspx
For a current Fee List and Detailed Fee Analysis, please visit our website at:
SOCIAL SECURITY NUMBER
(M.I.)
(First)
APPLICANT’S NAME (Last)
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)
Requested State Exam date: __________________________________
Please note, the National Exam is self-scheduled and instructions for completing registration will be mailed upon approval of this application.
Check box only if you require special accommodations during the examination. If special accommodations are required, please provide an
explanation below.
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
NHAP INITIALS _______________________
AIT #
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 (01/20)