Apply for a nursing home administrator license

You must provide all requested information. Failure to provide requested information may result in a delay in processing your application. Incomplete applications will be returned to applicant.

Completed Applications must include the following:

1. The following documents must be submitted at the same time in one envelope:
   1. A completed application form, signed and dated by the applicant and notarized
   2. A 2 x 2 passport style color photo (white or off-white background). Copies and printer generated photos are not acceptable.
   3. A signed and notarized Criminal Offender Record Information (CORI) Acknowledgement Form
   4. A check or money order, payable to the Commonwealth of Massachusetts, for the fee listed below
   5. Three professional references
      • Note: they can't be relatives, spouses, family members, subordinates ,or your AIT preceptor
   6. One personal reference.
      • Note: they can't be a spouse, partner, family member, subordinate or your AIT preceptor
   7. A completed physician form
   8. A completed Administrator Affidavit
      • Note: Provide a self-addressed envelope to your endorsers with your Reference Forms, Physician Form, and Administrator Affidavit Certificate of Internship Training. After the individual has completed the form, they must seal it in the return envelope you provide, sign their name across the envelope seal, and return it to you.
2. Official transcripts in signed, sealed envelopes for all undergraduate degrees and any other post-secondary degrees
   • When requesting official transcripts, please inform each school’s registrar that the transcript must be complete and state the degree and date conferred in mm/dd/yyyy format
3. Verification of licensure status, in signed, sealed envelopes, from any state or jurisdiction in which you now or have previously held any professional license. The state or jurisdiction must send verifications directly to the Board.
4. If you hold, or have ever held, any professional license or certification, you must request a National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank Self-Query and submit the Original report in a signed and sealed envelope with this application. To request a Self Query, please contact the National Practitioner Data Bank. Keep a copy for your records.
   • Note A: If you don't hold and have never held any professional licenses in any other state, you don't need to submit a National Practitioner Data Bank self-query