LARA/BPL-NHAEMPLOY (08/16)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
VERIFICATION OF NURSING HOME ADMINISTRATOR EMPLOYMENT
Authority: 1978 PA 368
This form must be submitted directly to this office by the hospital. If this form is submitted by the applicant, it will not be accepted.
Applicant’s Name (First, Middle, Last)
Name of Hospital
Address of Hospital
City
State
Zip Code
CERTIFICATION AND SIGNATURE
I certify the above-named applicant has been employed as a chief executive or administrative officer at a state-licensed
hospital from ______________________ to ______________________.
Date Date
_________________________________________________
____________________________________________
Signature of President/Director Date
_________________________________________________
Print or Type Name of President/Director (Seal) If hospital has no seal, please indicate.
click to sign
signature
click to edit
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