Application for Facility Training Site

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Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly.

 NAME OF FACILITY: __________________________________________________________

 ADDRESS: (Street) ___________________________________________(City) _____________

                            (State)__________________________ (Zip Code) ________________________

TELEPHONE: __________________________  (Fax) ___________________________

NUMBER OF LICENSED BEDS: _______________         COUNTY: _____________________

OWNER: __________________________________

Please provide the following information on the facility key staff and department heads:

NAME                       POSITION IN FACILITY DATE HIRED WORK HOURS TYPE OF LICENSE HELD LICENSE #

______________________________________________________________________________

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PLEASE ATTACH THE LATEST COPY OF YOUR SURVEY REPORT (HCFA 2567) WHICH INCLUDES YOUR PLAN OF CORRECTION AND A COPY OF YOUR FACILITY LICENSE ISSUED FROM THE DIVISION OF LICENSURE AND CERTIFICATION.