Free 42352.FH11 - Indiana

VERIFICATION OF EMPLOYMENT OF APPLICANTS FOR HEALTH FACILITY ADMINISTRATOR LICENSURE
State Form 42352 (R4 / 2-06)

* Social security number required pursuant to IC 4-1-8-1

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] www.pla.IN.gov

THIS FORM IS FOR ENDORSEMENT CANDIDATES ONLY.
APPLICANT INFORMATION
Name (last, first, middle, maiden) Address (number and street, city, state, and ZIP code) License number Date of issuance (month, day, year) Date of birth (month, day, year) Social Security number *

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

THE SECTION BELOW IS TO BE COMPLETED BY THE APPLICANTS EMPLOYER
Name of employer Name of facility where employed Address of facility (number and street, city, state, and ZIP code) Telephone number of facility Date employment began (month, day, year) Date employment ended (month, day, year)

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Position held Briefly describe duties of employee:

Type of facility Type of care offered

Number of beds

If employee was disciplined in any way while in your employ, please provide certified copies of all related documents. Thank you for your assistance. AFFIRMATION I hereby swear or affirm under penalties of perjury that the information provided herein is true and correct.
Form completed by (signature) Name of firm or business Address of firm or business (number and street, city, state, and ZIP code) Telephone number Date (month, day, year) Printed name and title

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