Fields marked with an asterisk (*) are required.
To receive your Assisted Living Administrator license, please complete this application, together with
  • A Copy of Nursing Home Administrator's license
  • A Copy of NHA license renewal card
  • A Copy of State license of the assisted living facility for which you have administrative responsibility
  • Alabama Immigration Affidavit Form

Mail the exhibits to:
Alabama Board of Examiners of Assisted Living Administrators
2740 Zelda Road, Suite 3B
Montgomery, AL 3610

Personal Information
*NHA License Number:
*License Expiration Date: (ex: mm/dd/yyyy)
*First Name:
*Last Name:
*Social Security Number: (ex: xxx-xx-xxxx)
*Date of Birth: (ex: mm/dd/yyyy)
*Home Mailing Address:
*City:
*State:
*Zip Code: (ex: xxxxx-xxxx)
*Home Phone Number: (ex: xxx-xxx-xxxx)
Email Address: (ex: address@host.com)
Version 2.0.6