Free 52638.FH11 - Indiana

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START NOTIFICATION FOR ADMINISTRATOR- IN-TRAINING PROGRAM
State Form 52638 (R / 11-08)

INDIANA STATE BOARD OF HEALTH FACILITY ADMINISTRATORS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

May this memorandum serve as notification to the Indiana State Board of Health Facility Administrators that I, ___________________________________________, a licensed administrator and approved preceptor in the State of
printed name of preceptor

Indiana, license number ________________________, began the approved administrator-in-training program, as prescribed in 840 IAC 1-1-15, for ____________________________________ on the _______ of _____________________, ____________.
printed name of administrator-in-training day month year

Signature of preceptor

Date (month, day, year)

Signature of administrator-in-training

Date (month, day, year)