Free 42353.FH11 - Indiana

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VERIFICATION OF ADMINISTRATOR-IN-TRAINING PROGRAM
State Form 42353 (R5 / 12-08)

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]

* Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. THIS FORM IS FOR ENDORSEMENT CANDIDATES ONLY.
APPLICANT INFORMATION
Name (last, first, middle, maiden) Social Security number *

Address (number and street, city, state, and ZIP code)

License number

Date of issuance (month, day, year)

Date of birth (month, day, year)

I hereby authorize _______________________________________________________ to furnish the Professional Licensing Agency with the information below.
Signature of applicant Date (month, day, year)

THIS SECTION IS TO BE COMPLETED AND AUTHORIZED BY THE STATE BOARD Yes No The individual referred to above completed an administrator-in-training program for licensure in our state. (If yes, complete the section below.)
Length of training program

Name of facility where training took place

months
Address (number and street, city, state, and ZIP code)

hours

Preceptor / Supervisor of training program

Type of program

Type of facility

Residential Care
Form completed by (printed name)

Comprehensive Care

Title

Please affix Board seal

Signature

Date (month, day, year)