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.
*Name of assisted living facility currently requiring an acting administrator with an emergency permit:
*Please document circumstances creating the need for an emergency permit for the above listed facility:
*What is the length of time an emergency permit will be needed?:
*Name of the previous administrator of the above listed facility:
*Administrator License Number of the previous administrator of the above listed facility:
   




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