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 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.

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

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

Link to forms used for the Manager Certificate Application

Arizona Statement of Citizenship Form: https://nciaboard.az.gov/resources/statement-citizenship-form

Character Certification Form: https://nciaboard.az.gov/resources/character-certification-form

5-Year Residence History: https://nciaboard.az.gov/resources/5-year-resident-history

5-Year Employment Record Form: https://nciaboard.az.gov/resources/5-year-employment-record

Paycheck Hours Worked Tracker: https://nciaboard.az.gov/resources/paycheck-hours-tracker

Board-Approved Manager Training and Caregiver Training

Please review the attached document for instructions prior to starting your application for an Administrator License.

For applicants needing to complete an Administrator-in-Training Program (AIT) in Arizona or need information on how to become an AIT Preceptor, please contact:

Administrator-in-Training Program Advisory Committee
Arizona Chapter, American College of Healthcare Administrators
Misti Valentino-AIT PAC Chair
Cell: (702)-273-7800
[email protected]

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

This spreadsheet can be used when submitting individual paycheck stubs to calculate hours worked.

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

Request for a Copy of Original Certificate or License