CABOT AR 72023
ADMINISTRATOR CERTIFICATION PROGRAM
TELEPHONE NUMBER: FAX: EMAIL:
MEMBERSHIP STATUS: FACILITY ASSOCIATE NONMEMBER
GOOD STANDING JOINING TODAY
SOCIAL SECURITY NUMBER -- -- DATE OF BIRTH
EDUCATIONAL LEVEL: HIGH SCHOOL/GED SOME COLLEGE COLLEGE GRAD
HIGHEST DEGREE HELD NURSING OR SOCIAL
Please indicate any and all of the areas in which you have had experience by entering the approximate amount of time you have worked in that position.
COMMERCIAL HOUSEKEEPING MAINTENCE
I understand that to be eligible to work as an administrator of a Residential Care Facility or Assisted Living Facility in the state of Arkansas that I must meet certain requirements established by law and regulation and that successful completion of this program fulfils only the certification requirement. I also understand that the Arkansas Residential Assisted Living Association assumes no responsibility for any consequences attributed to or related to any use or interpretation of any information or views presented through this training program.
Signature (office use)