30 Miss. Code. R. 2703-1.2 - Application(s)

A. Administrator-in-Training (A.I.T.) Application

An applicant for the A.I.T. Program shall file a written or electronic application, on the forms prescribed and furnished by the Board, pay all applicable fees, and furnish evidence satisfactory to the Board that he or she has met all licensure requirements as specified in Rule l.l.A.(l) - (6) of Chapter 1, Part 2703 of these Rules and Regulations. The application form is available from the Board office or the Board website.

The applicant shall submit to the Board the following:

(1) satisfactory proof of age, which must accompany the application;

(2) letters from three (3) references, who shall certify to the good moral character of the applicant, and shall be from individuals who have engaged in either business or professional work with the applicant, but shall not be related by blood or marriage;

(3) a statement, which must accompany the application from the applicant's physician as to the health of the applicant, specifically, his or her physical ability to perform the duties of a nursing home administrator;

(4) a finished unmounted recent photograph of himself or herself for identification. This photograph must be attached to the application, must not be less than 2" x 3" in size and must be signed by the applicant on the back;

(5) a transcript, bearing the official seal of the educational institution, which must be submitted to the Board office directly from the institution, for the purpose of documenting successful completion of college credits by the applicant;

(6) if applicable, a signed statement from the applicant's current nursing home administrator describing the duties the applicant has performed, the number of employees he or she has supervised, and any other information concerning the applicant's work experience for at least the past two (2) consecutive years immediately prior to making application with the Board.

(7) payment for the current application fee in the amount set forth on the application to cover the costs associated with processing the application. The fee which is non-refundable, must accompany the A.I.T. application.

(8) Satisfactory proof that:

(a) a criminal records check that has been performed on the applicant to be sent directly to the Board's administrative office directly from the employing institution. This document must be signed and notarized; or

(b) a state and federal criminal background to be sent to the Board's administrative office directly from the appropriate governmental agency.

The applicant shall be responsible for the payment of any fees or costs associated with the state and federal criminal record checks. Such costs or fees shall be paid by the applicant to the agency completing the record check. Criminal record checks must have been performed on the applicant within six (6) months immediately prior to the filing of the Administrator-in-Training Program Application or the Endorsement Application or a new criminal record check shall be required.

(9) if the applicant has at any time held a certification or license, he or she must provide satisfactory proof that no formal discipline has been taken against any and all of those certifications or licenses.

(10) a completed Certificate of Employment form and A.I.T./ Preceptor Agreement form, or proof of completion of an equivalent A.I.T. program in Long Term Care Administration from an academic institution as stated in Part 2703, Chapter 1, Rule l.lA.(6)(b). The appropriate document must accompany the application.

B. Endorsement Application

An applicant for licensure by Endorsement shall file a written or electronic application on forms prescribed and furnished by the Board, pay the applicable fees, and furnish evidence satisfactory to the Board that he/she has met all licensure requirements specified in subsections (1) - (6) of Rule 1.1.

Rule l.l.B(l) - (2) and in subsections (1) - (9) of Rule I.2.A. of Chapter 1, Part 2703.

The applicant shall also furnish the Board with:

(1) satisfactory proof that the applicant completed an A.I.T. Program as specified in Rule I.3.B., Chapter 1, Part 2703;

(2) satisfactory proof of a current nursing home administrators license in at least one (1) other state and that there has been no formal discipline taken against any license in any state the applicant has held a license;

(3) satisfactory proof that the applicant is employed or will become employed in a Mississippi nursing home. The applicant shall attach to the application a completed Certificate of Employment form; and

(4) satisfactory proof of the applicant's NAB Examination Score which must consist of a Scale Score of at least 113.

C. Temporary Permit Application

An applicant requesting a temporary permit in the state of Mississippi shall file a written or electronic application on forms provided by the Board, pay the applicable fees, and furnish evidence satisfactory to the Board that he or_she has met all licensure requirements specified in subsections (1) - (6) of Rule 1.1. A., Rule l.l.B.(l) - (3), subsections (1) - (9) of Rule 1.2. A., Rule 1.23.(1) - (4) of Chapter 1, Part 2703 of these Rules and Regulations. The applicant must furnish the Board with a written explanation, with supporting documentation,that clearly justifies why the temporary permit is needed.

D. Applications for Licensure

After compliance with all of the requirements of Rule 1.1. A., B., and/or C, as applicable, of Chapter 1, Part 2703, the applicant shall file with the Board a written or electronic Application for Licensure, signed under penalty of perjury, on the form prescribed by the Board and provide such other information as the Board may require. Only complete applications shall be presented to the Board for approval. A complete application shall include all information requested on the form, the applicable fee(s), and all materials required by the Board for verification that the applicant meets all licensure requirements.

The basic requirements for suitability set forth herein above are to be considered minimal and may not be waived.

E. The Board may designate a time and place at which an applicant may be required to present himself for inquiry as to his suitability as provided for herein.

The applicant shall be required to meet all the requirements of this and all other applicable laws and rules as prerequisite to sitting for the examinations as identified in Part 2703, Chapter 1, Rule 1.5.

All application fees are non-refundable and must accompany all applications at the time of filing with the Board. No applications will be considered until the applicable fees are paid.

Notes

30 Miss. Code. R. 2703-1.2

Miss. Code Ann. Sections 73-17-7(2), 73-17-9(b) and (d)(Rev. 2008); and Miss. Code Ann. Section 73-17-11 (Supp. 2011).

Amended 12/1/2014 Amended 11/20/2015