STATE OF ________________________)
COUNTY OF ______________________)
EMPLOYMENT VERIFICATION AFFIDAVIT
Before me, the undersigned Notary Public in and for said County, in said State,
personally appeared ______________,
who is known to me and who, being duly sworn on oath deposes and says:
The affiant is _________________________________________of
________________________________
(Title - owner, co-owner, officer, director, etc.)
(Nursing facility)
and is personally acquainted with ________________________________, who is an applicant for a license as a
nursing home administrator under the rules governing nursing home administrators
licensed under the laws of the State of Alabama, and that applicant has been employed by
the nursing facility from ____________to_____________.
(Date) (Date)
That applicant has good moral character and reputation where he/she resides, and enjoys the confidence and respect of the general public. His/Her duties are summarized as follows with dates indicated where appropriate to reflect major duty changes or changes in responsibility: ____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
____________________
Affiants Signature
Sworn to and subscribed before me
this _____day of __________, 19___.
____________________________
My Commission Expires ______________
Notary Public
County of _________________
State of __________________