Fillable form to the NC State Board of Examiners

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NC STATE BOARD OF EXAMINERS FOR NURSING HOME ADMINISTRATORS
3733 National Drive, Suite 110
Raleigh, NC 27612
919/571-4164
CHARACTER REFERENCE
The State Board of Examiners for Nursing Home Administrators is required by Federal and State
law to determine the qualifications, skill, fitness, and suitability of any person who applies for a
license to practice as a nursing home administrator in the State of North Carolina.
Your assistance with this evaluation, by responding to all of the items below and returning this
form to the NC State Board of Examiners for Nursing Home Administrators as soon as possible,
will be appreciated. All information that you provide will be considered confidential and will be
maintained in this manner.
______________________________________________________________________________
______________________________________________________________________________
NAME OF THE PERSON FOR WHOM THIS REFERENCE IS BEING GIVEN
______________________________________________________________________________
ADDRESS ____________________________________________________________________
HOW HAVE YOU BEEN ASSOCIATED WITH THIS PERSON? _______________________
______________________________________________________________________________
ARE YOU RELATED TO THIS PERSON? _____ BY BIRTH ____ BY MARRIAGE ____
PLEASE COMMENT ON HIS/HER CHARACTER, PARTICULARLY WHETHER YOU
CONSIDER THIS PERSON TO BE REPUTABLE AND RESPONSIBLE.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
please continue on back
TO YOUR KNOWLEDGE, HAS THIS PERSON EVER BEEN CONVICTED OF A CRIME
OTHER THAN A MINOR TRAFFIC VIOLATION? _____ IF YES, PLEASE COMMENT.
______________________________________________________________________________
______________________________________________________________________________
ARE YOU AWARE OF ANY PERSONAL TRAITS, HABITS, OR CONDUCT WHICH
WOULD MAKE HIM/HER UNSUITABLE TO SUPERVISE THE CARE OF THE
RESIDENTS OF A SKILLED FACILITY? _____ IF YES, PLEASE COMMENT.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
BASED ON YOUR KNOWLEDGE OF THIS PERSON, WOULD YOU RECOMMEND
HIM/HER FOR EMPLOYMENT AS A NURSING HOME ADMINISTRATOR? _____ IF NO,
PLEASE COMMENT.
______________________________________________________________________________
______________________________________________________________________________
_______________________________
Signature (Please print name below)
_______________________________
_______________________________
Mailing Address
_______________________________
Employer (Self-employed give name and type of business)
_______________________________
Date
PLEASE RETURN TO: NC State Board of Examiners for
Nursing Home Administrators
3733 National Dr., Suite 110
Raleigh, NC 27612
charactr.doc
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form to the NC State Board of Examiners

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Completed 4 February 2022

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