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LIC 9214 - Application for Administrator Certification

Application FOR Administrator CERTIFICATIONADMINISTRATOR Certification PROGRAMI nstructions:See page 2 for complete instructions.(1)Type of Application :(Check one box only. If renewing, provide certificate numberand expiration date.) New RenewalCertificate #_____ Expires: _____(2)Type of Program:(Check one box only; if applying for more than one certificate,submit separate Application for each.) ARF (Adult Residential Facility) GH (Group Home) RCFE (Residential Care Facility for the Elderly) STRTP (Short Term Residential Therapeutic Program)(3)Applicant Information:(Please print.) Check here if any information has changed since last (First, MI, Last): _____Address (Street Address, City, State, Zip): _____Telephone Number: _____ Cell: _____ E-mail: _____Social Security Number:*_____ Date of Birth: (MM/DD/YY)_____(a) Do you currently hold or have you previously held a license, Certification or other approval as a professional in aspecified field ( , RN, NHA)?

Application for Administrator Certification (form LIC 9214 (05/16)) A . check or money order . for $100 payable to the Department of Social Services (OR . for $300 if you’re renewing after your certificate expired). Please include your administrator certificate number on your check. Paper clip your check to your documents; do not staple or glue.

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