Fields marked with an asterisk (
*
) are required.
Application For Emergency Permit
Please note that the person completing this application must meet the following criteria:
The person must be at least 19 years of age.
The person must be a citizen of the United States of America or has duly declared their intention of becoming a citizen of the United States of America.
The person must be of good moral character and suitable and fit to practice as an assisted living administrator.
the person must, at least, have a high school diploma or GED.
The person must be eligible to be licensed by reciprocity,
or
must have worked in an assisted living facility or for a management company that operates assisted living facilities in a supervisory capacity for a minimum of two years prior to their appointment as acting administrator.
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Name of assisted living facility currently requiring an acting administrator with an emergency permit:
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Please document circumstances creating the need for an emergency permit for the above listed facility:
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What is the length of time an emergency permit will be needed?:
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Name of the previous administrator of the above listed facility:
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Administrator License Number of the previous administrator of the above listed facility:
Policy Related Questions: (334) 239-7044Technical Support: 866-353-3468 or
support@alabamainteractive.org
Version 2.1.6
