Forms

  • Forms that are marked with a Y in the Fill column can be completed on-line through Adobe Acrobat Reader.
  • Users with Adobe 6.0 and above will need to change a setting before completing the forms so that the tabbing order works correctly. Open Adobe Acrobat, go to the tab on top labeled Edit, go to Preferences, and Accessibility. Make sure the box Use document structure for tab order when no explicit tab order is specified is not checked.
  • Dates must be entered in the following format: mm/dd/yyyy.
  • When printing a form from Adobe Acrobat, the Page Scaling needs to be set to None. This can be found under File, Print, Page Handling Section. There will be a section called Page Scaling with drop down options. Please select None from those options. If any of the other options are selected, additional white space will be added to the margins of the form and the form will shrink.

Board of Nursing Home Admin - Public Form(s)

SFNTitleSizeDateFillable
60364 INTENT TO APPLY FOR A ND NURSING HOME ADMINISTRATOR LICENSE 420 kb 04/15/2015 Y
60365 STATE BOARD ENDORSEMENT QUESTIONNAIRE 528 kb 04/15/2015 Y
60366 EMERGENCY LICENSE REPORT 400 kb 04/15/2015 Y
60367 CRIMINAL HISTORY RECORD CHECK AUTHORIZATION 370 kb 10/26/2016 Y
60368 APPLICATION FOR INIITAL LICENSURE AS A NSG HOME ADMIN 769 kb 08/12/2016 Y
60369 APPLICATION FOR RENEWAL OF NSG HOME ADMIN LICENSE 673 kb 08/12/2016 Y
60370 APPLICATION FOR LICENSURE AS NGS HOME ADMIN BY ENDORSEMENT 693 kb 08/12/2016 Y
60371 APPLICATION FOR EMERGENCY LICENSURE AS NSG HOME ADMIN 692 kb 08/12/2016 Y