NEW YORK STATE DEPARTMENT OF HEALTH
Board of Examiners of Nursing Home Administrators
Nursing Home Administrator
Licensure Application
DOH-641 (5/22) Page 1 of 5
All Applicants
Ensure that all required sections of your application are complete and legible. Failure to submit a complete application will delay the
processing of your application.
Include a copy of your Social Security card to verify your social security number.
Include a copy of one identification form to verify your age (driver’s license, ID card for non-drivers, passport or birth certificate).
Contact your academic institution(s) requesting an official transcript be sent by the institution directly to the Department or by e-script to
[email protected].gov.
Include either Addendum A or Addendum B (not both) along with the required documentation for each form (below).
Sign and date your application in the presence of a Notary Public.
Keep a copy of your application and all supporting documentation.
Return your completed application with original signature, any required attachments and $40 fee, in the form of a check or money order
payable to the New York State Department of Health to:
NEW YORK STATE DEPARTMENT OF HEALTH
Board of Examiners of Nursing Home Administrators
Bureau of Professional Credentialing
875 Central Avenue
Albany, New York 12206
All Addendum A- Administrator-In-Training Program (AIT) applicants must include the following:
Program plan – Participation in the Administrator-In-Training Program requires the advance written approval of the Board. The training
sites, preceptors and interns must meet specific criteria to be approved by submitting a description of the learning activities for each module
(including goals and objectives) at least eight weeks prior to the desired start date of the internship.
Organization chart – A current organization chart for the training site identifying the incumbents in all positions at the department head
level and above.
All Addendum B - Qualifying Field Experience applicants must include the following:
Proof of salary and title – Documents must be provided with job title and salary (such as a payroll report or paystubs)
Organization chart – An organization chart on facility letterhead signed and dated by the administrator-of-record or authorized representative
of human resources is required.
Job description – A job description on facility letterhead signed and dated by the administrator-of-record or authorized representative of
Human resources is required.
Out-of-State Licensed Nursing Home Administrators must complete the following:
Request Licensing Board Verification – All verifications must be in the form of a letter on official letterhead (affixed with a state seal) and
include as much of the following information available: your name, license number, date license issued, examination taken, examination
date, examination score (raw score and scale score), registration status, expiration date and disciplinary action (if any).
Request Score Transfers – Candidates can request a score transfer directly from the National Association of Long Term Care Administrator
Boards (NAB) testing company. While an exam score will automatically be reported to the jurisdiction for which the exam was taken, a
request will need to be made using one of the methods below to transfer your scores to additional states. Please contact NAB directly for
information and applicable fees.
It is unlawful for you to practice or represent yourself as the Administrator-of-Record of a nursing home in New York State in the absence of a
current New York State registration. Doing so may result in sanctions by the Board.
NURSING HOME ADMINISTRATOR APPLICATION CHECKLIST
PERSONAL INFORMATION
Last Name First Name Middle Initial
List all Previous Last Names
Home Street Address Apt. #
City/Town/Village State Zip Code
Social Security Number (attach a copy of your Social Security card) Date of Birth
County of Residence
Gender (Optional): Male Female X
E-mail Address (Preferred):
E-mail Address (Secondary):
Phone (Home):
Phone (Work):
Phone (Cell):
Cashline:
Expiration Date:
Approved _______/_______/_______
Other _______/_______/_______
Comment(s)
Reviewer:
Office Use Only
EDUCATION INFORMATION
Check all that apply (for demographic purposes only).
GED/High School Diploma Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral Degree
PROFESSIONAL INFORMATION
List all professional licenses and/or certificates you currently hold or have held in the past (attach additional sheets, as necessary).
License/Certificate License/Certificate # Date Issued State or Jurisdiction
License/Certificate License/Certificate # Date Issued State or Jurisdiction
License/Certificate License/Certificate # Date Issued State or Jurisdiction
EMPLOYMENT INFORMATION
Enter your employment information.
Current Job Title Former Job Title
Employer Employer
Address Address
Dates of Employment Dates of Employment
Supervisor Supervisor
DOH-641 (5/22) Page 2 of 5
Current Position
Former Position
NEW YORK STATE DEPARTMENT OF HEALTH
Board of Examiners of Nursing Home Administrators
Nursing Home Administrator
Licensure Application
QUALIFICATION 1 (AGE)
QUALIFICATION 2 (CHARACTER AND SUITABILITY)
Age: ►►►►► Driver license, ID card for non-drivers, passport or birth certificate must be submitted (attach only one).
Academic Institution/Degree (with Major)
Date Degree Conferred
(Month/Year)
Have you ever been convicted of a crime (felony or misdemeanor) in any state or country?
Have you ever been charged with a crime (felony or misdemeanor) in any state or country, the disposition of which was other than acquittal
or dismissal?
Have you ever surrendered your license/certificate or been found guilty of professional misconduct, unprofessional or unethical conduct,
incompetence or negligence in any state or country?
Are charges pending against you for professional misconduct, unprofessional or unethical conduct, incompetence or negligence in any
state or country?
Has any hospital, nursing home or licensed facility restricted or terminated your professional training, employment or privileges, or have you ever
voluntarily resigned or withdrawn from such association to avoid imposition of such measures?
Do you currently have a mental, physical or emotional health condition which impairs or limits or, if untreated, could impair or limit your ability to
practice as a nursing home administrator in a competent and professional manner?
Have you ever entered into a stipulation of settlement or similar agreement to settle a charge relating to professional misconduct, unprofessional
or unethical conduct, incompetence or negligence in any state or country?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Bachelor's Degree (Minimum)
Required Course Work
Courses will be considered for 10 years from the date of successful completion, with the exception of Nursing Home Administration,
which will be considered for five years from the date of successful completion.
►►
Check if you are claiming two or more years of service as the full-time Administrator-of-Record of an out-of-state nursing facility within the last five years as a substitution for the
required course work and proceed to Qualification 4 (Addendum B must be submitted). (Also applies to Qualification 5 [enter separately]).
Academic Institution/Course Name and Number Date Completed
Course
Nursing Home Administration
(300 level [or equivalent] or higher)
(Enter separately for Qualification 5)
Health Care Financial Management
(300 level [or equivalent] or higher)
Legal Issues in Health Care
(300 level [or equivalent] or higher)
Gerontology
(Introductory level or higher)
Personnel Management
(Introductory level or higher)
►► Degree(s) and course work being claimed to satisfy Qualification 3 must be supported by an official transcript sent by the academic institution.
►►
QUALIFICATION 3 (EDUCATION)
DOH-641 (5/22) Page 3 of 5
QUALIFICATION SUMMARY
►►
If you answered “Yes” to any of the above questions, a letter providing a complete explanation of the issue(s) must be submitted.
Include copies of any court records, including a Certificate of Disposition, Certificate of Relief from Disabilities or Certificate of Good Conduct.
►►
►►
NEW YORK STATE DEPARTMENT OF HEALTH
Board of Examiners of Nursing Home Administrators
Nursing Home Administrator
Licensure Application
DOH-641 (5/22) Page 4 of 5
Qualification 2 (Character and Suitability)
Check the field experience and any substitution or reduction you are claiming. You must complete either an internship or qualifying field experience, not both.
Only one substitution or reduction may be claimed.
Administrator-In-Training Program (Internship) (Minimum 12 months)
(Addendum A must be submitted).
Substitution or reduction:
Three or more years of full-time service as a Director of Nursing Services at
a qualifying health care facility (Internship Credit: 6 months).
Two or more years of service as the full-time Administrator-of-Record of an
out-of-state nursing facility within the last five years (Full Satisfaction).
Internship at a nursing facility completed as part of an accredited educational
institution degree requirement (Full Satisfaction).
Internship at a nursing facility completed as part of the nursing home administrator
licensure requirements of another state licensure board (Full Satisfaction).
Master’s Degree and completion of the five courses required to satisfy Qualification 3.
(Internship Credit: 6 months)
OR
Field experience being claimed to satisfy Qualification 4 must be supported by the applicable field experience documentation (Addendum A or B).
You must arrange to have the Administrator-of-Record or Authorized Representative of Human Resources at each facility
from which you are claiming qualifying field experience complete and submit Addendum B.
Master’s Degree reduction must be supported by an official transcript sent by the academic institution and certificate (if applicable).
►►
►►
►►
►►
Qualifying Field Experience (Minimum 2 years)
(Addendum B must be submitted).
Substitution or reduction:
Three or more years of full-time service as a Director of Nursing Services at a
qualifying health care facility (Field Experience Credit: 12 months).
Two or more years of service as the full-time Administrator-of-Record of an
out-of-state nursing facility within the last five years (Full Satisfaction).
Master’s Degree and completion of the five courses required to satisfy Qualification 3.
(Field Experience Credit: 12 months)
Enter name(s) of provider(s) from which field experience is being claimed and documentation will be submitted (attach additional sheets, as necessary).
Job Title
Employer
Job Title
Employer
Job Title
Employer
Check if you are claiming a substitution for the Nursing Home Administration course.
A current Nursing Home Administrator certification issued by the American College of Health Care Administrators (ACHCA) (Certificate must be submitted).
Two or more years of service as a full-time Administrator-of-Record of an out-of-state nursing facility within the last five years (Addendum B must be submitted) (From Qualification 3).
Course Academic Institution/Course Number and Name Date Completed
Nursing Home Administration
(300 level [or equivalent] or higher)
(From Qualification 3)
Dates of Employment
Dates of Employment
Dates of Employment
Check if Addendum B has been requested from the facility
Total Service Claimed:
Check if Addendum B has been requested from the facility
Total Service Claimed:
Check if Addendum B has been requested from the facility
Total Service Claimed:
QUALIFICATION 4 (FIELD EXPERIENCE)
QUALIFICATION 5 (COURSE OF STUDY)
NEW YORK STATE DEPARTMENT OF HEALTH
Board of Examiners of Nursing Home Administrators
Nursing Home Administrator
Licensure Application
New York State General Obligations Law, Section 3-503, requires everyone applying for or renewing a professional license, permit or registration to file a written statement that, as of the
date of the filing, he or she is, or is not, under an obligation to pay child support. Individuals who are four months or more in arrears in child support may be subject to suspension of
their business, professional and/or driver licenses. The intentional submission of false written statements for the purpose of frustrating or defeating the lawful enforcement of support
obligations is punishable pursuant to Section 175.35 of the Penal Law.
You must complete this section before the license for which you have applied is issued. Individuals who are under an obligation to pay child support but are not in compliance with the
General Obligations Law can be issued a license for no more than six months to discharge child support obligations consistent with the Law.
Check only one below:
I am not under an obligation to pay child support.
I am under an obligation to pay child support and (please check only one of the following):
I am current and am not four months or more in arrears in the payment of child support; or
I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties; or
The child support obligation is the subject of a pending court proceeding; or
I am receiving public assistance or supplemental security income; or
None of the above four statements apply (you must submit a letter of explanation with your application).
SERVICE IN THE ARMED FORCES
Did you serve in any of the Armed Forces of the United States?
If you served, were you discharged under favorable conditions? If you answered “No”, a copy of your
Discharge Certificate must be submitted.
Yes No
Yes No N/A
I affirm, subject to the penalties for perjury, that the statements made herein and on the accompanying documents have been examined by me and to the best of my knowledge and belief
are true and correct. I further understand that a false statement knowingly made by me may be cause for suspension or annulment of any license issued pursuant to this application.
Applicant Signature Date
Sworn to before me this day of , 20
Notary Public
Notary Stamp
Organ donors save lives. If you would like to be an organ and tissue donor upon your death, you may enroll in the NYS Donate Life Registry online at
www.donatelife.ny.gov/register. Opting out of enrolling in the NYS Donate Life Registry will not impact or impair my ability to obtain services from the
Bureau of Professional Credentialing.
NOTARIZED SIGNATURE
DOH-641 (5/22) Page 5 of 5
You must receive a passing score on the Nursing Home Administrator Licensing Examination. To be eligible to sit for the examination, you must satisfy Qualifications 1-5. The Nursing Home
Administrator Licensing Examination developed by the National Association of Long Term Care Administrator Boards is the only examination approved by the Board of Examiners of Nursing
Home Administrators for licensure as a nursing home administrator in New York State. If you hold a nursing home administrator license issued by another state and are requesting a waiver of
the examination requirement, you must submit documentation from the issuing state that you took and passed the examination.
CHILD SUPPORT OBLIGATION
QUALIFICATION 6 (EXAMINATION)
ORGAN AND TISSUE DONATION INFORMATION
NEW YORK STATE DEPARTMENT OF HEALTH
Board of Examiners of Nursing Home Administrators
875 Central Avenue
Albany, New York 12206
[email protected].gov or 1-877-877-1827
AFFIRMATIONS AND CERTIFICATIONS
NEW YORK STATE DEPARTMENT OF HEALTH
Board of Examiners of Nursing Home Administrators
Nursing Home Administrator
Licensure Application
