Form NH-1 "Application for Nursing Home Administrator License" - New Jersey

What Is Form NH-1?

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

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the New Jersey Department of 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 printable version of Form NH-1 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form NH-1 "Application for Nursing Home Administrator License" - New Jersey

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New Jersey Department of Health
Nursing Home Administrators Licensing Board
APPLICATION FOR NURSING HOME ADMINISTRATOR LICENSE
Mailing Address:
Overnight Services (UPS, FedEx, Airborne):
PO Box 358
25 South Stockton Street, 2nd Floor
Trenton, NJ 08625-0358
Trenton, NJ 08608-1832
INSTRUCTIONS: Complete as much information as possible on the form itself, then attach additional sheets as necessary
and number the response(s) to correspond to the numbers listed on this form. Please print or type.
1. Name of Applicant
2. Name of Licensed Long Term Care Facility Site
Street Address
Street Address
City, State, Zip
City, State, Zip
3. Social Security No.
4. Date of Birth
5. Place of Birth
6. U.S. Citizen
7. Date of Naturalization
Yes
No
If no, attach copy of green card declaration of independence.
8. Home Telephone Number
9. Work Telephone Number
10. Email Address
(
)
(
)
11. Have you ever been convicted of a crime or offense (other than traffic violations)?
No
Yes-Explain:
12. Type of Program
Administrative Intern Program
Equivalency-Graduate School Program
License by Equivalency (Reciprocity)
(N.J.A.C. 8:34-4.2)
(N.J.A.C. 8:34-4.4)
(N.J.A.C. 8:34-6.8)
13. PROFESSIONAL EXPERIENCE - Start with present or most recent position and work back.
A. Name and Address of Employer, Firm or Organization
B. Title of Position
C. Dates of Employment
D. Hours Worked Per Week
From:
To:
E. Description of Duties
A. Name and Address of Employer, Firm or Organization
B. Title of Position
C. Dates of Employment
D. Hours Worked Per Week
From:
To:
E. Description of Duties
A. Name and Address of Employer, Firm or Organization
B. Title of Position
C. Dates of Employment
D. Hours Worked Per Week
From:
To:
E. Description of Duties
NH-1
MAY 16
Page 1 of 2 Pages.
New Jersey Department of Health
Nursing Home Administrators Licensing Board
APPLICATION FOR NURSING HOME ADMINISTRATOR LICENSE
Mailing Address:
Overnight Services (UPS, FedEx, Airborne):
PO Box 358
25 South Stockton Street, 2nd Floor
Trenton, NJ 08625-0358
Trenton, NJ 08608-1832
INSTRUCTIONS: Complete as much information as possible on the form itself, then attach additional sheets as necessary
and number the response(s) to correspond to the numbers listed on this form. Please print or type.
1. Name of Applicant
2. Name of Licensed Long Term Care Facility Site
Street Address
Street Address
City, State, Zip
City, State, Zip
3. Social Security No.
4. Date of Birth
5. Place of Birth
6. U.S. Citizen
7. Date of Naturalization
Yes
No
If no, attach copy of green card declaration of independence.
8. Home Telephone Number
9. Work Telephone Number
10. Email Address
(
)
(
)
11. Have you ever been convicted of a crime or offense (other than traffic violations)?
No
Yes-Explain:
12. Type of Program
Administrative Intern Program
Equivalency-Graduate School Program
License by Equivalency (Reciprocity)
(N.J.A.C. 8:34-4.2)
(N.J.A.C. 8:34-4.4)
(N.J.A.C. 8:34-6.8)
13. PROFESSIONAL EXPERIENCE - Start with present or most recent position and work back.
A. Name and Address of Employer, Firm or Organization
B. Title of Position
C. Dates of Employment
D. Hours Worked Per Week
From:
To:
E. Description of Duties
A. Name and Address of Employer, Firm or Organization
B. Title of Position
C. Dates of Employment
D. Hours Worked Per Week
From:
To:
E. Description of Duties
A. Name and Address of Employer, Firm or Organization
B. Title of Position
C. Dates of Employment
D. Hours Worked Per Week
From:
To:
E. Description of Duties
NH-1
MAY 16
Page 1 of 2 Pages.
APPLICATION FOR NURSING HOME ADMINISTRATOR LICENSE (Continued)
Name of Applicant
Social Security No.
14. EDUCATION
List colleges, universities and professional schools you have attended. Attach copies of all transcripts.
Attach additional sheet if necessary.
Dates
Major Area
Minor Area
Name and Location of School
Graduated
Diploma/ Degree
Attended
of Study
of Study
From:
Yes
To:
No
From:
Yes
To:
No
From:
Yes
To:
No
15. PROFESSIONAL CERTIFICATES AND/OR LICENSES HELD
Include such items as Licensed Nursing Home Administrator, MD, RN, LPN, CPA, etc. Do not include
academic degrees. Give complete information for each license you hold or have ever held.
Attach additional sheet if necessary.
Exp. Date of
Action Taken
Year of
Year of
Current/Latest
Type of Certificate or License
Name of State
Current Cert. or
Against This
Original Issue
Latest Issue
Reg. Number
License
License?
Yes
No
Yes
No
16. Explanation of action taken against license:
17.
THE ITEMS DESCRIBED BELOW MUST ACCOMPANY THIS APPLICATION
a. If you are currently employed in a health care facility, name of the facility and current license number of the facility
b. Organization chart for the administrative body of the facility
c. Current job description
d. Three (3) letters of reference from individuals, not related to you, who will attest to your good moral character and administrative ability
e. Official college transcript
18. FEE INFORMATION
APPLICATION MUST BE ACCOMPANIED BY A NON-REFUNDABLE FEE OF $100.
MAKE CHECK OR MONEY ORDER PAYABLE TO: “TREASURER, STATE OF NEW JERSEY.”
CHECK/MONEY ORDER NUMBER
DATE OF CHECK/MONEY ORDER
AMOUNT OF FEE ENCLOSED
19. CERTIFICATION
State of ____________________________________ ss:
County of ___________________________________
I affirm that I am the applicant and that I have examined the contents of this application and the accompanying documents and that the statements in
this application and the accompanying documents are true and correct to the best of my information and knowledge.
Signature ________________________________________________________________________________________
Subscribed and sworn to before me this _______ day of ____________________, A.D. 20________
At ________________________________
My commission expires ___________________________________
_________________________________________________________
Signature of Officer Administering Oath
NOTE: All documents become the property of this Department and will not be returned to the applicant.
NH-1
MAY 16
Page 2 of 2 Pages.
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