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Board Forms

Administrator or Manager request form

Forms

Administrator or Manager request form for individual continuing education approval.  The form must be filled out and uploaded with the service request in the elicense portal.

CEU extension request form

Forms

CEU extension request form can be used between April 30th and July 31st to request an extension of time to complete the CEU requirement for license or certificate renewal.  The form must be filled out and uploaded with all required attachments as a service request in the elicense portal.

CEU renewal form

Forms

CEU renewal form for an approved sponsor CEU course that has not expired.  This form must be filled out and mailed with a check for the fees.
 

Change of Address

Forms

To change your mailing address fill out the attached form and follow the instructions to submit the form. 

Duplicate Administrator License request form

Forms

Duplicate Administrator License request form must be filled out and uploaded with the service request in the elicense portal.  Mail or fax forms will not be accepted.

Duplicate Manager Certificate request form

Forms

Duplicate Manager Certificate request form must be filled out and uploaded with the service request in the elicense portal.  Mail or fax forms will not be accepted.

Letter of Intent to Appoint a Temporary Administrator

Forms

Letter of Intent to Appoint a Temporary Administrator.  This form should be submitted with an initial application for temporary licesne or uploaded with the service request in the elicense portal.  Mail or fax forms will not be accepted.

Letter of Intent to Appoint a Temporary Manager

Forms

Letter of Intent to Appoint a Temporary Manager.  This form should be submitted with an initial application for a manager certificate or uploaded with the service request in the e-licensing portal. Mail or fax forms will not be accepted.

Notice of Appointment request form

Forms

Notice of Appointment request form needs to be uploaded with the service request in the elicense portal when an Administrator or Manager either starts or ends a facility appointment.

Public Records request form

Forms

Public Records request form is use for requesting copies of public records from the Board or requesting administrator and manager mailing lists.

Sponsor request form

Forms

Sponsor request form to teach a CEU course or CEU conference for Administrators or Managers.  This form must be filled out and mailed or emailed along with the required attachments and check for the fees.