New Mexico Regulation and Licensing Department

BOARDS ANDCOMMISSIONS DIVISION

New Mexico Nursing Home Administrators Board

Toney Anaya Building ▪ 2550 Cerrillos Road ▪ Santa Fe, New Mexico 87505

(505)476-4622 ▪ Fax(505)476-4665 ▪

APPLICATIONFORLICENSURE

SelectbyEXAM or by RECIPROCITY.
LICENSURE BYEXAM
$200 ApplicationFeepayableto NM NHA Board
$200 LicenseFee payable toNMNHA Board upon notification directly fromtheNMNHA Boardthat you successfully passed theNAB/NHA exam.
*National StandardsExamFee andcomputer-based
testingsite fees arepayableelectronically directly to
NAB (National ExaminingBoard)at the time ofyour
online applicationto take the NAB/NHA exam. / LICENSUREBYRECIPROCITY
$200.00 ApplicationFee
$125.00Temporary Permit*(Optional)
*Theapplication,application fee,andcopyof currentNHA license must be submittedwithrequest forTemporary Permit. Temporary Permits arevalid onlyfor 120 days.(See
16.13.5.11NMAC).
$200.00Licensure Fee
SECTIONI: PERSONALINFORMATION
First Name:_Last Name:_MI: SSN: _-_ - DOB: -_ - Maiden Name (ifapplicable) Street Address: MailingAddress City, State, Zip Code: Home Phone: WorkPhone: E-mail PRINT NAME EXACTLY AS YOU WISH IT TO APPEAR ON LICENSE:
Current Employer name, address andzip: E-mail Address:
Employment Start Date/Current Employer-_-Position Held:
SECTIONII:IDENTIFICATIONPHOTOGRAPH
SIGN thebackofthephotoin thepresence ofa notary beforeattaching.
Attachsigned PASSPORTphoto here.
NotarySignature
SECTIONIII:EDUCATIONALINFORMATION
A Baccalaureate Degreeis theminimumeducational requirement (NursingHomeAdministratorsAct, Section61-13-8, NMSA 1978).
Enclose a copy of yourBaccalaureateDegree
Makearrangements to haveall official transcript(s),uptoand includingyourBachelor's degree, sentdirectly to theBoard
office by the institution.
Youmay alsowishto haveon file,acopyof additional education obtained after yourBachelor'sdegree. Master's Degree Other:
EDUCATIONAL RECORD (continued)
University / AddressofInstitution / FieldofStudy / DegreeType / DateAwarded

SECTIONIV:LICENSUREHISTORY

With reference tothe following questions, the terms “license,” “registration,” and“certification” are consideredto be

synonymous.Be aware,theBoardhas access tonational disciplinarydata banks.

YESNO Doyou now hold or have you inthe past held a professional license(s),i.e.,Nursing HomeAdministrator, SocialWorker, Registered Nurse, etc.?IfYES, list thefollowinginformation here. Finish at thebottomof the page4 if morespace isneeded.

State / LicenseTitle / LicenseNo. / IssueDate / Expiration Date

Send acopyof theVERIFICATIONOFLICENSUREREQUESTformto all state licensing boardswhereyouhavebeenlicensed as a NURSINGHOMEADMINISTRATOR

Ifyou holdlicensesinotherprofessions,have those licensing boardssendletters verifyingthestatusof yourlicense(s), including disciplinaryhistory,directly totheNMNHA Board.

Note: Toavoiddelays,contactall licensingboardsorjurisdictionsfirst toinquire ifthere is a feefor this service.

SECTIONV:DISCIPLINARYHISTORY

If youanswerYES to anyof the followingquestions,attach explanations, relevant documentation,and current status.

YESNO (1)Haveyouever hadasuit filedagainst you relatedtothepracticeof nursinghomeadministration?

YESNO (2)Haveyou hadalicenseto practiceaprofession revoked,suspended, or otherwisesanctioned?

YESNO (3)Have you been refusedaninitial license orrenewal ofa license dueor pursuant to disciplinary proceedings?

YESNO (4)Haveyou knowinglyfailedto renew alicenseduringaninvestigation or disciplinary action; or haveyou failedto complete the terms of adisciplinary finding,agreement, or finalorder ina licensing jurisdiction by just ignoring or notrenewing yourlicense?

YESNO (5)Haveyou beenarrestedfor DWI(DUI),or in any other mannerbeen disciplined by thecourts,by an employer,or by a licensing jurisdiction for the illegaluseof controlled substances or the abuseof alcohol or other drugs orintoxicants?

YESNO (6)If youanswered Yes to (5), are you currently participatingin a supervised rehabilitation programor professional assistance programthatmonitors you in order toassure that you are not engaged inthe illegal use of controlledsubstancesor that youare not engaging intheabuse of alcohol or other drugs or intoxicants?

YESNO (7)If you answeredYesto(6),provideacopyofyourcontractwiththe MonitoredTreatmentProgram.

YESNO (8)Tothe best ofyour knowledge, is there any disciplinary action pendingagainst you by anylicensing

board/jurisdiction,professional society, or examiningagency?

YESNO (9)Have you beenarrested, charged or sentencedforthe commission ofafelony or any crimeinvolvingmoral corruption?

YESNO(10)Are youcurrentlymore than a monthinarrears in court ordered child supportpayments in New Mexico or any other state(s)?

SECTIONVI:ADMINISTRATOR-IN-TRAINING(A.I.T.)PROGRAM

YESNO Haveyoucompletedan A.I.T.program? Please encloseacopyof your Certificate ofCompletionof the

A.I.T.programandcomplete the following:

Dates# of Hrs.Facility NameandAddressPreceptor NamePhone#

SECTIONVII:WORKHISTORY
Provideinformation aboutyourpresent (ormostrecent)joband thenwork backward.Cover at least thepast 12yearsor all of the time sinceyou left school. You may omit temporaryjobsunlesstheyare relevant tothe health profession.Ifnecessary, copy this pagebefore completing and attach extrasheets if necessary.All informationrequested mustbesupplied.
Checkhere if aRésumé is submittedin lieu of completingthefollowing.Inordertobeacceptable,a separaterésumé
mustprovideall informationrequestedbelow.
Firm’s NamePhoneDatesEmployedYour Title
/ / to //
Firm’sAddress Supervisor’s Name YourDuties:
Firm’s NamePhoneDatesEmployedYourTitle
/ / to //
Firm’sAddress Supervisor’s Name YourDuties:
Firm’s NamePhoneDatesEmployedYourTitle
/ / to //
Firm’sAddress Supervisor’s Name YourDuties:
Firm’s NamePhoneDatesEmployedYourTitle
/ / to //
Firm’sAddress Supervisor’s Name YourDuties:
Firm’s NamePhoneDatesEmployedYourTitle
/ / to //
Firm’sAddress Supervisor’s Name YourDuties:
SECTIONVIII:REFERENCES
Contact threepeople to providewritten moral characterreferencesfor you, to be sentdirectly tothe Board,andlist thembelow. Reference letters mustbefrom persons notrelatedtoyou,and must containtheaddressand phone numberofthereferencein the event the Board wishes tocontact themdirectly. Letterson letterhead willmeet these criteria.
Reference’s NameRelationshipAddressof ReferencePhonenumber
This application mustbesignedin the presence ofa Notary Public.
SECTIONIX:CERTIFICATION
I,THE UNDERSIGNED, do hereby affirmunder penaltyof perjury thatall statements madeandinformationcontainedin this applicationare trueandcorrect tothebestof my knowledge and belief.Further, I consent toa thoroughinvestigation of my employment recordand otherinformationthatmay benecessaryto verify my qualificationsforpracticeasanursing home administrator.
Signatureof ApplicantDate
SECTIONX:NOTARYPUBLIC
Applicantname (print) on this dayof ,20 _,personally appeared beforeme, identifiedand verifiedtome as the person whosename is subscribedtothe aboveinstrument,and whohasacknowledged thesame tobehis/her own freeact and deed.
State of
Signatureof Notary
County of
MyCommissionexpires

Seal

.